Inspection on 01/02/06 for John Wills House

This inspection was carried out on 1st February 2006.

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

John Wills House 19/04/07

John Wills House 31/08/05

John Wills House 15/03/05

John Wills House 31/07/04

John Wills House 24/02/04

Similar services:

Manor Lodge

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE John Wills House Jessop Crescent Westbury Fields Westbury on Trym Bristol BS10 6TU Lead Inspector Vanessa Carter Announced Inspection 09:30 1st & 2 February 2006 nd 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 John Wills House DS0000046239.V272340.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. John Wills House DS0000046239.V272340.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service John Wills House Address Jessop Crescent Westbury Fields Westbury on Trym Bristol BS10 6TU 0117 3773700 0117 3773725 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) St. Monica Trust Mrs Angela Rosalind Healey Care Home 60 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (45), of places Physical disability (3) John Wills House DS0000046239.V272340.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to fifteen older people including two adults (aged forty years and over with a physical difficulty) requiring planned short-term care may be accommodated in the respite care wing. Of the fifteen, up to eight Service Users entering the Beeches Unit may be accommodated for a period of time not exceeding twelve months. This may include respite, intermediate and nursing care. Fifteen older persons with dementia who require personal care only to be accommodated in `The Orchards` wing. Up to thirty older persons requiring nursing care to be accommodated in `The Willows` on the first floor. This may include one named person aged forty-six onwards, with a physical disability. This placement is specific for one individual and the condition will lapse if the placement ceases 31st August 2005 2. 3. Date of last inspection Brief Description of the Service: John Wills House is a purpose built care home, built and owned by St Monicas Trust. It is registered with the Commission for Social Care Inspection (CSCI). The home is situated in Westbury Fields Retirement Village. In addition to the home there is a complex of sheltered housing, retirement apartments and bungalows - these do fall under the remit of CSCI. The home is well appointed and shares its building with a purpose built pub - the Cricketers. John Wills House is registered to provide different levels of care in each of the three units: • The Willows provides placement for 30 residents, both male and female who require nursing care. All rooms are for single occupancy, with ensuite facilities and ceiling fitted hoist mechanisms. • The Orchards provides placement for 15 residents, both male and female with personal care and dementia care needs. • The Beeches, is again for 15 male and female residents, but only on a short term/respite basis. A number of the beds are block booked by South Gloucestershire PCT and Bristol City Council. John Wills House DS0000046239.V272340.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows a planned inspection to the home that took place over two days. This was a full inspection with the majority of standards being assessed. Evidence has been gained from:• Information provided by the manager in the pre-inspection questionnaire • Six service user comment cards • Nine relative comment cards • a tour of the home • speaking with a number of the residents, • speaking with a number of relatives and visitors • speaking with the care home manager and deputy care home manager • speaking with registered nurses and nursing care assistants. The service provided at John Wills House is classed as being of excellent quality, with substantial strengths in many areas. What the service does well: What has improved since the last inspection? Improvements have been made to the homes admission processes, thereby ensuring that comprehensive assessments are undertaken, and placement is offered to those whose needs can be met. John Wills House DS0000046239.V272340.R01.S.doc Version 5.0 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. John Wills House DS0000046239.V272340.R01.S.doc Version 5.0 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 John Wills House DS0000046239.V272340.R01.S.doc Version 5.0 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, 4, 5 and 6 Residents are given clear information regarding the service, enabling them to make an informed choice before considering a move there. Improvements to the pre-admission assessment process ensure that placement is appropriately offered. Intermediate care is provided in The Beeches, and residents are assisted to regain their independence and return home. EVIDENCE: The homes Statement of Purpose and Service Users Guide has been reviewed and updated to reflect changes and provide some additional information for prospective and existing residents. A copy of the document is placed in each bedroom, having been personalised to whichever unit, with staff details and photography. John Wills House DS0000046239.V272340.R01.S.doc Version 5.0 Page 9 The home uses the ‘easycare’ assessment tool for all new admissions. This is a comprehensive document that covers all aspects of a person’s personal care needs, daily living, health and social care. The homes policy is that all new residents will have been assessed prior to being offered placement. This is to ensure that the home is able to meet the person’s needs. The assessments of the most recently admitted residents were examined – these had been signed by the assessor and dated. They evidenced that the assessment had been completed prior to admission to the home. The unit manager on The Orchards explained that a minimum of two assessment ‘visits’ to the home, are arranged for prospective residents, to assess suitability for admission and compatibility with the other residents. The person will visit the home for two separate day periods to ‘trial’ the home. This is good practice. The home has three units. The Willows is a 30-bedded nursing care unit for older people who have a wide range of complex medical conditions. The Orchards is a 15-bedded dementia care unit for those with personal care needs. Although registered nurses work on the unit, community-based nursing services are requested to meet any health care needs. The third unit is the Beeches and this provides intermediate care, and short stay placements for a wide range of scenarios. The Intermediate Care Unit, the Beeches, has separate communal facilities from the rest of the home. South Gloucestershire PCT Intermediate Care Team have ‘block purchased’ five of the beds and staff on the unit will provide care for these residents, working in conjunction with the ICT staff to enable the people to return to their own homes. In addition two beds are funded by Bristol City Council who use them for planned respite. The unit has a rehabilitation kitchen and a physiotherapy department. Most residents length of stay is 2 - 6 weeks, however the home does have a condition of registration that states that up to eight residents are able to remain on this unit for a maximum period of up to one year. John Wills House DS0000046239.V272340.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, 8, 9, 10 and 11 Residents can expect to be well cared for in respects of their health, personal and social care needs. The care planning processes ensure that a detailed picture of each person’s needs are obtained and residents can be assured that their individual needs will be met. Medications systems are well managed. EVIDENCE: Seven care planning files were looked, two from The Orchards but three each from The Willows and The Beeches. The plans were person- centred and had obviously been written in conjunction with the resident and any of their family. They included the preferred name to be used and any information regarding the family and specific needs. The identified needs were clearly set out with instructions for the staff in how these needs should be met. The plans had been reviewed on a monthly basis and amended as necessary. Where equipment had been identified as essential to maintaining the residents comfort this was detailed upon the plan of care. John Wills House DS0000046239.V272340.R01.S.doc Version 5.0 Page 11 The plans were supported with assessments in respects of the likelihood of developing pressure sores, risk of falls and nutritional needs. Whilst the first two were regularly reviewed, nutritional assessments were not updated following admission into the home. The format of the document does not lend itself to recording a review, however the home must provide evidence that each residents nutritional needs have been kept under review, particularly during times of changing need and deteriorating health. Three of the plans looked at, contained information that did not reflect a true picture of the person’s needs. Despite this minor shortfall in the homes documentation, there was no evidence that residents’ nutritional needs were not being met. All residents seen during the two days of the inspection, looked well nourished. Daily communication sheets are maintained and completed by both the health care assistants and registered nurses. This is good practice and ensures that the member of staff who delivers the care, then makes a record of that care given. Each entry was signed in line with good record keeping guidelines. The home maintains records for each resident showing their contact with other health care professional such as the GP, psychiatric services and chiropody. Discussions with one of the registered nurses and observations made, evidence that the home has robust procedures in place for the ordering, receipt, administration and disposal of medications. Residents can be assured that they will receive their medications correctly. Residents are cared for with respect to their dignity and their privacy. Personal care is provided in private and staff were observed to knock on doors before entering a room. All bedrooms are fitted with privacy locks that can be over-ridden in case of emergency. During the course of the visit, all the staff were observed interacting well with the residents, being friendly and attentive. One visitor said that they were always welcomed and offered refreshments, and still felt “valued” as part of their relatives care team. Since the last inspection, the home has looked at their policy in respect of resident’s wishes not to be actively resuscitated in the event of a sudden illness. The policy is written from St Monica’s Trust perspective, and does not solely relate to John Wills House. Despite this being a sensitive subject, the home has consulted with the resident, their GP and any relevant family or representatives, where this is appropriate. Residents can be assured that the staff will look after them in the manner in which they wish, when it comes to ‘end-of-life’ care. John Wills House DS0000046239.V272340.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 and 15 The residents have plenty of opportunity to participate in a stimulating and varied life, and are encouraged to maintain contact with family and friends. They are able to spend their time as they wish. The meals provided are of a very good quality. EVIDENCE: The home provides a range of social functions each day that residents can choose whether or not to participate in. “You are able to come and go as you please” was one persons comment. During the course of the inspection a number of activities were observed - six residents were attending an art session, the poetry reading session was popular, and the “Recall Therapy” was very well attended. It is obvious from discussions with residents that there is always plenty going on. A weekly plan of activities is posted throughout the home and includes shopping trips, music sessions and religious worship. To the side of the home there is The Cricketers Pub - this is well used by the residents, their visitors and those who live in the retirement apartments and sheltered flats in the Westbury Fields Village. A number of the residents have partners and friends who live in the village, and therefore this facility enables them to still be able to “go out for lunch”. John Wills House DS0000046239.V272340.R01.S.doc Version 5.0 Page 13 The home has an open visiting policy and it is obvious that relatives and friends are seen as being essential to maintaining a resident’s well being. One visitor stated that she enjoyed visiting the home and added that her mother was provided with the best social life ever. Residents are encouraged to make decisions about all aspects of their daily life. This may include choosing where to take a meal, where to spend their time, or what time to get up in the morning and what time to retire to bed at night. Observations were made of the midday meal. In the Willows unit, there is now “two sittings”. One person commented that this made mealtimes a much nicer experience, as it was quieter and calmer. A choice of menu is offered at each mealtime and residents do not have to decide what they want to eat the next day. One resident commented, “I’ve just had a very nice lunch – same as always. They feed us very well”. Meals can be taken in the pleasant dining rooms on each of the units or in the resident’s own room. John Wills House DS0000046239.V272340.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): 16 and 18 Residents and visitors can be assured that any complaints they have are listened to and acted upon, and that they will be cared for by staff who will safeguard and protect them. EVIDENCE: The complaints procedure is contained within the homes Statement of Purpose and the Welcome Pack placed in each person’s room. Each resident spoken to was aware that the home had a complaints procedure, but none had had reason to make any complaints. One described the home as “top notch”. The home has had a small number of complaints since the last inspection – each had been handled appropriately and it was evident from the clear records maintained by the home, that the complainants were informed of the outcome and any actions taken. Staff spoke knowledgeably about adult abuse issues and stated what they would do if unacceptable care practices were observed. All new staff are issued with documentation about adult protection protocols (No Secrets) and all staff are expected to undertake adult abuse awareness training at the organisations training department. Information regarding ‘Protection of Vulnerable Adult (POVA)’ procedures, along with the homes whistle blowing policy, is displayed in the three nursing work- stations. Observations made of interactions between staff and residents, demonstrated that the residents are well cared for and safe. John Wills House DS0000046239.V272340.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): 19, 20, 21, 22, 23, 24, 25 and 26. Residents live in a comfortable and safe home, that is fully equipped to meet their needs and is maintained to the highest of standards. EVIDENCE: The home is nearly three years old and complies with all the regulations for newly built care homes. Both inside and out the buildings are well maintained. The gardens surrounding the home are well tended. It is built within the “Westbury Fields” Village, in addition to retirement apartments and sheltered flats. Westbury Fields is entered via electronically operated gates. The call button console, that needs to be operated to enter the site, is located on the left hand side (the passenger side) of the driveway. This means that visitors travelling alone would need to get out of their car to use the call bell. The company that installed the equipment, are unable to relocate this due to the layout of the road, therefore St Monica’s have displayed telephone numbers for visitors to ring, if they need assistance. This does assume that all disabled visitors to the site will have a mobile telephone. John Wills House DS0000046239.V272340.R01.S.doc Version 5.0 Page 16 The home is a two- storey building, entered via a large and pleasant reception area. The reception area is staffed during ‘office hours’. The nursing unit, on the first floor, can be accessed by one of two lifts, or a stairway, thereby it is fully accessible for older and disabled people. The Orchards unit and The Beeches are both on the ground floor. In order to prevent the residents in The Orchards from wandering off, the door into the unit is key padded and all other exits from the unit are linked into the alarm call system. The three units each have their own lounge area and dining room. The furniture and soft furnishings are of a superior quality, making the rooms a very pleasant space in which to relax and take a meal. Attached to the home is “The Cricketers Pub” and this is used by many of the residents, particularly when entertaining their visitors and family. Each of the bedrooms is for single occupancy, spacious and with ensuite bathroom facilities. The ensuite rooms in the Beeches are fitted with facilities that can be moved to accommodate different residents needs. The rails can be raised and lowered, as can the wash hand basin and shower units. All rooms are fitted with tracked ceiling hoists, thereby reducing the need for bulky manual hoists to be used – these tracks continue into the shower rooms. In addition, there are specialist bathrooms and toilets located throughout the home. Residents are encouraged to bring in their own possessions and furniture. Each resident’s room is furnished with quality furniture and fittings. The majority of beds are specialist beds that will aid resident’s comfort and assist the care staff when giving personal care. The soft furnishings are elegant and matching bed linen is provided. The home was warm and well lit, and each room is well ventilated. All parts of the home are tastefully decorated and furnished throughout. In general the bedrooms are decorated in between residents. The home is spotlessly clean, tidy and odour free in all areas. Air freshener units are installed in the corridors and perfume the air without being overpowering. John Wills House DS0000046239.V272340.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, 28, 29 and 30 Residents are cared for by staff who are skilled and competent to do their jobs, so they can be assured that their needs will be met. Robust recruitment procedures ensure that the right staff are employed at the home. EVIDENCE: The home is as usual, running with full occupancy. The recent vacancies have already been earmarked for new residents. The appropriate numbers of staff were on duty to meet the resident’s needs. The manager maintains an overview of dependency levels on each of the three units, and will amend staffing levels accordingly. The home has unit managers for both The Orchards and The Beeches, but is currently without one for The Willows. The home manager is herself, meeting this shortfall in the interim, and job advertisements have already been placed. The home has 17 registered nurses and 43 care staff, and each worker is ‘employed’ for a specific unit. The care staff are supported by 30 ancillary staff, in meeting the residents daily living tasks. The home does not need to use Agency staff as it has a number of bank staff who will work as and when required. This ensures consistency of care for the residents. John Wills House DS0000046239.V272340.R01.S.doc Version 5.0 Page 18 Of the current nursing care assistants, 84 have already obtained at least, a National Vocational Qualification in Care, at Level 2. The commitment to providing trained members of care staff is to be commended and reflects upon the quality of the service provided. The home follows a robust recruitment procedure with prospective employees expected to complete an application form and attend for interview. Two written references, CRB and POVAfirst clearance are obtained for all new recruits. The staff files of three recent recruits confirmed this to be the case. The homes procedures ensure that the right staff are employed at the home and that the residents will be cared for by staff who will safeguard and protect them. St Monica’s Trust has a specific training department, and the courses they provide can be purchased by other care providers. They have an annual training and development plan and examples of training sessions include first aid, infection control, food hygiene, fire, manual handling, care of vulnerable people, principles of care and specific health related topics. Each staff member has a training file that evidences the training they have undertaken. A sample of these files were checked and the information verified by the staff member. John Wills House DS0000046239.V272340.R01.S.doc Version 5.0 Page 19 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): The home is well managed and has clear and effective leadership. Residents’ interests are promoted and safeguarded. EVIDENCE: The manager has been in post since the home opened three years ago. She is a registered nurse and has completed her Registered Managers Award. A deputy care manager, unit manager and heads of department assist in the running of the home. From discussions with residents, relatives and staff, it is evident that the manager has a “hands on” approach to her job and maintains a visible presence in the home. Staff reported that they felt listened to and that their opinions were valued. Residents meetings, relatives meetings and staff meetings ensure that the home is run in the best interests of those who live there. John Wills House DS0000046239.V272340.R01.S.doc Version 5.0 Page 20 The home also undertakes regular ‘customer satisfaction surveys’. Resulting from this an annual plan for each of the units is drawn up. In addition to this all residents leaving The Beeches, the short term care unit, are asked to complete an assessment of their stay. This evidences that the home look seriously at how they provide their service and want to ensure it remains appropriate and meets resident’s needs. The home holds personal monies for those residents who require the service. Good administrative procedures and record keeping evidenced that resident’s funds are safe. A random sample of resident’s funds was checked against the records and was correct. The home has a planned programme of staff supervision for all staff members. The manager supervises the qualified staff and cascades responsibility for the supervision of junior staff members to these staff. Newly recruited staff are allocated a mentor who will assist them to settle into their job, ensure they work to the homes policies and procedures and standards, and complete the induction training programme. Records evidenced that all necessary fire checks and drills are undertaken on a regular basis, and maintenance contracts are all in place. Risk assessments are carried out for all safe-working practices and records are maintained when any restrictive measures (use of bed rails) need to be taken to secure a residents safety. The home has robust health and safety procedures to ensure that the home remains a safe place in which to live and to work. John Wills House DS0000046239.V272340.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 X 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 4 3 4 3 3 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 John Wills House DS0000046239.V272340.R01.S.doc Version 5.0 Page 22 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 OP7 Regulation 15(2) Requirement Where needs have been identified, nutritional assessments and care plans should be reviewed and updated as appropriate. Timescale for action 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations John Wills House DS0000046239.V272340.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 John Wills House DS0000046239.V272340.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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