Inspection on 28/02/07 for Kings Acre

This inspection was carried out on 28th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Kings Acre 10/01/06

Kings Acre 17/05/05

Kings Acre 05/01/05

Kings Acre 20/07/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

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 Kings Acre Ermington Nr Ivybridge Devon PL21 0LQ Lead Inspector Rachel Proctor Key Unannounced Inspection 28th February 2007 10:30 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 Kings Acre DS0000003591.V324368.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. Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kings Acre Address Ermington Nr Ivybridge Devon PL21 0LQ 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) 01548 830076 01548 831470 kingsacre@tesco.net Mr Michael Leaves Mrs Georgina Tracy Linnell Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (6), Physical disability over 65 years of age (28) of places Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named, physically disabled service user, aged 50 years and over can be accommodated. 10th January 2006 Date of last inspection Brief Description of the Service: Kings Acre is a 34-bedded care home set in its own grounds on the edge of Ermington Village. The house has been converted and extended but still keeps its original charm, with views of the local countryside. The atmosphere within the home is warm and friendly; the registered Provider makes every effort to maintain a family feel to the home whilst providing nursing and personal care to its elderly, physically disabled service users. Registered nurses are available on duty 24 hours a day to monitor Service Users health. The home admits persons over the age of 65 years of either gender. The statement of purpose and service users guide is provided in the office of the home. Residents and their representatives can request a copy if they wish. The fees payable were given from £380 for those residents requiring residential care to £640 for those residents requiring nursing from 18.01.07. Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which took place on 28.02.07 between 10:30 am and 4pm. The inspector spoke to resident’s staff and the management team at Kings Acre during the inspection. Four residents had their care followed. A tour of the home was completed and some records were inspected. Prior to the visit to the home the inspector received nine residents comment cards, eight relatives comment cards, five health professionals comment cards. Some of the comments made in these and comments made during the inspection have been incorporated into this inspection report. What the service does well: What has improved since the last inspection? What they could do better: Any improvements made will build on already good practice at Kings Acre. Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 6 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. Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. 1, 2, 3 This judgement has been made using available evidence including a visit to this service. The residents and their representatives have enough information to make an informed choice about whether Kings Acre can meet their needs. They can have confidence that their care needs will be assessed and met by staff who are trained to do so. EVIDENCE: The statement of purpose is revised annually. Copies of this were available during the inspection for residents and visitors. This gives prospective residents and their relatives the opportunity to make an informed decision about the home. Each of the residents whose care was followed had a contract of care, which gave clear information about the terms and conditions with the home. The owner advised that fees are reviewed annually. And letters informs all residents and/or their representatives about the increase in cost. Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 9 The manager has introduced a comprehensive assessment process for residents. The four residents whose care was followed had clear assessments in place. These provided information about the individual residents health, personal care and social care needs. The assessments also provided clear information about what the residents liked and disliked and what was important to them. The residents who had care management assessments or healthcare assessments following discharge from hospital had these contained with the care plan documentation. One resident whose care was followed had been in the home for some time had had their assessment repeated. During the inspection an NHS nurse was assessing some of the residents for the nursing they required. They advised that the information available to them in the individual residents plans of care provided “clear information about the health care needs of that individual”. They further commented “the staff at Kings acre provided excellent care for their residents”. Four health professionals comment cards were received prior to this inspection. All were complimentary about the way health care is delivered by the staff team at Kings acre. Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent, 7, 8, 9, 10 This judgement has been made using available evidence including a visit to this service. The residents have their health, personal and social care needs assessed and provided by a competent caring staff team, who have their best interests at heart. EVIDENCE: Four residents had the care followed as part of this inspection. Each of these residents had a plan of care, which had been developed from a comprehensive assessment of their care needs. The care plans set out the actions needed by care staff to ensure all aspects of the health and personal care are addressed. The care planning included risk assessments for manual handling and risk of falls. Where a risk had been identified the care plan guided staff how to reduce the risk of falls for the individual resident. Each of the plans of care reviewed had been reviewed monthly or sooner if the residents care needs had changed. The manager advised that where possible the residents are encouraged to sign their care plans. Examples of these were seen. Four Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 11 residents spoken to told the inspector that staff had discussed their care needs with them. The information contained in the care plan supported this. The individual residents personal preferences and choices have been recorded. This included how they wanted to be addressed their likes and dislikes for food and the sort of activities they enjoyed. The care plans viewed demonstrated how the residents had access to health care services to meet their assessed needs. One resident whose care was followed had a record of the other healthcare professionals who had seen them. The health professionals included speech therapists, physiotherapist and specialist nurses. Where these health professionals have made recommendations about the way health care should be delivered, the care plan had been changed to include this advice. One resident told the inspector the physiotherapist had told them what they needed to do to improve their mobility and staff were helping them to do this. How staff should do this was recorded in their plan of care. The assessment process identifies the pressure sore risk for residents. Each of the residents whose care was followed had a completed pressure sore risk assessment. High dependency pressure relief mattresses were seen in use for the residents who required them. A clear wound care planning system had been introduced. This evidenced wound healing and provided the staff with clear information about the dressings used. Continence assessments had been completed for each of the residents whose care was followed. The care plans identified how continence could be promoted or how incontinence should be managed. Continence aids and equipment were provided for those residents that needed them. The care planning documentation included psychological health care monitoring. Where this had been identified as an issue for one resident; a plan of care guided staff how to care for this residents psychological needs. Two residents told the inspector “staff are always friendly and helpful towards them”. Staff observed caring for the residents were doing so in a respectful friendly manor that valued the residents personal preferences and choices. Residents had an identified GP who provided their medical care. When a resident had seen their GP this was recorded in their plan of care. Any change in treatment requested by their GP had been incorporated into the plan of care. NHS funded care assessments had been completed by an NHS nurse for those residents who needed nursing care. One registered nurse spoken to during the inspection advised that they had access to training that helped them care for the residents and information about the disease processes of old age was available as reference material in the office. One resident told the inspector “the staff understood their care needs and helped them to keep feeling well”. Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 12 The resident’s medication is stored in a locked treatment room and lockable drug trolley. The records of medication given were seen for the four residents whose care was followed. These had been completed and signed in line with good practice. Where the GP had changed medication for one resident this had been added to and changed on the residents medication record. The controlled drug record was checked against the stock held for one resident and stock disposal record as correct. Where medication had been disposed of this had been recorded and signed by two staff. A record of medication received for individual residents was also being kept. The registered nurse giving medication during the inspection advised that the local supply pharmacist provided advice and support for medication issues in the home. Medication reference books were available in the treatment room. The inspector was advised that none of the current residents are able to self medicate. A completed self-medication assessment template was provided, which had been used to assess the resident’s ability to self-medicated. The manager had provided the Commission with information about how staff should manage crushed medication, soon after the last inspection. Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good, 12,13,14,15 This judgement has been made using available evidence including a visit to this service. The routines of the home continue to be flexible to try to meet individual residents needs and preferences. EVIDENCE: Nine comment cards were received from residents they generally indicated that activities were usually provided for them. One commenting, “I enjoy the activities”.” there are activities arranged I sometimes join in”. When asked if the home helped them to keep in touch with their relative (resident). Three of the eight relatives who responded indicated that they always do this, One indicated they usually do and four indicated that it was not applicable. Comments received included “staff can always have a word with me if necessary”, they always bring them to the phone when I ring”. Other relative’s comments included, ”Kings Acre provides a welcoming, homely atmosphere with good food & good staff”. “In the time that my aunt has been at Kings Acre we have always been made to feel welcome”. Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 14 Visitors were coming and going through out the inspection. Residents were seeing their relatives in the privacy of their own room or in one of the communal areas in the home. Visitors spoken to during the inspection were complimentary about the care and services provided at Kings Acre. A list of activities for the month was displayed on a notice board in the resident’s communal lounge. The residents asked told the inspector that they looked forward to the activities. One commenting that they enjoyed having a sing a long with one of the entertainer who visits. Another said they sometimes do exercises to music, which they found enjoyable. The way individual residents care is recorded and planned shows that they were involved with the development of their plan of care. The residents whose care was followed had a record of their personal preferences and choices and what interested them. One comment card received indicated that they would like more trips out. The manager advised that they were planning to offer trips out when the weather improved later this year. The lunchtime meal observed was attractively presented and nutritional balanced. The residents were eating their meals at their own pace. Those residents that needed assistance were being given this one to one by a staff member. The staff observed helping the residents to eat their meals were speaking to them as they assisted. This appeared to be making the meal time a pleasant experience for them. The chef advised that all the meals are prepared from fresh produced, which is locally sourced where possible. They also advised that they had received information about the food hygiene legislation and one of the staff was attending the training sessions being provided by the environmental health department. Comments received during the inspection from residents included “the food is good and plenty of it”,” excellent food”, “we are offered a choice if we don’t like what’s on offer that day although that doesn’t happen very often”. All the comment cards received form residents indicated that they liked the food provided for them. Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good, 16,18 This judgement has been made using available evidence including a visit to this service. The staff at Kings Acre appear to have a genuine regard for the residents, which should enable them to express their concerns and wishes freely EVIDENCE: The residents were seen expressing their concerns and wishes freely to the staff who were caring for them. The complaints policy and procedure was easily available in the reception area of the home. The manager advised that she operates an open door policy, which enables relatives, residents and staff to speak to her if they have any concerns. The nine comment cards received from residents indicated that the majority knew who to speak to if they had any concerns. The residents asked during the inspection indicated that they would speak to the manager or owner if they had any concerns the care staff were unable to deal with. The Commission has received one complaint since the last inspection this was not fully substantiated. The records of concerns raised by residents were provided for inspection. This included the action the manager had taken to address the concerns and the response received. Policies and procedures are in place to guide staff how to respond to suspicions, evidence of abuse or neglect to ensure the protection of the residents. A record of training received by staff was provided. This was also Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 16 seen in the staff files viewed during the inspection. The staff records supported that the home manager has a robust recruitment policy and practice that protects residents from unsuitable staff. Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good, 19,26 This judgement has been made using available evidence including a visit to this service. The residents have a well maintained pleasantly decorated home to live in, which continues meets their changing needs. EVIDENCE: Several residents’ rooms and the ground floor corridor had had carpets replaced since the last inspection. Redecoration of individual residents rooms had also continued since the last inspection. Warn carpets noted at the last inspection had been replaced. The homes is attractively decorated and reasonably well maintained, providing a homely environment for the residents. The toilets and bathrooms are easily accessible for the communal areas and individual residents rooms. The home has 14 en-suit single rooms and 3 en-suit shared rooms. Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 18 The residents who require height adjustable beds have been provided with these. Several pressure relief mattresses were in use during the inspection. The manager advised that some new hoists and other equipment had been purchased since the last inspection. The manager also commented that staff received regular up dates for manual handling and received training with the new equipment. Central heating radiators are provided in resident’s rooms, which can be adjusted to meet the needs of the residents. During a tour of the home residents rooms were being heated to different temperatures to meet their needs. Two house keepers/domestic staff were working in the home during the inspection. The home was fresh and clean in all areas entered during the inspection. The comment cards received prior to the inspection indicated that the home is always fresh and clean. Residents spoken to during the inspection also said the home is always fresh and clean. They also commented that their clothes are cared for well. Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent, 27,28,29,30 This judgement has been made using available evidence including a visit to this service. A competent, well-trained caring staff team provide care for the residents in a way that promotes their individuality. EVIDENCE: A duty rota is provided, which shows the number of staff on duty each shift and what role they have in the home. The manager provided a copy of the monthly dependency tool she uses to plan the staffing levels for the home. The tool records the dependency of the residents and the number of staff needed to meet the needs of the residents. The tool also enables the manager to review the staffing number provided against the dependency needs of the residents. The resulting graphs provided for November 06 showed that the staffing numbers were exceeded for the dependency levels of the residents. Copies of dependency rating completed since were also available. Two members of staff spoken to stated that the staffing levels enabled them to provided good quality care for the residents. One resident spoken to during the inspection said the staff are friendly and supportive and nothing is too much trouble for them. One relatives comment card said, “They provide care with love”. Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 20 The pre inspection information indicated that eight of the nineteen care staff had achieved an NVQ level 2 in care or above. It also indicated that a further five staff were working towards this qualification. The induction staff receive has been reviewed and up dated since the last inspection. This broadly covers the Skills for Care guidelines. The manager advised that the new induction programme would be used for all new staff joining the home. The manager operates a robust recruitment policy, which protects the residents from unsuitable staff. Each of the staff files viewed during the inspection had two references on file. The manager and owner confirmed that no staff are employed in the home until they have a satisfactory police check returned. All the staff files seen had evidence of a police check being obtained prior to the staff member starting work. Copies of staff contacts, terms and conditions of employment were seen in the staff files. The manager advised that all staff have a training and development plan, which is developed at the annual appraisal and reviewed as the year progresses. One staff member employed since the last inspection advised that they had access to training to improve their knowledge and skills. They also said the manager was “very approachable and helpful and had discussed their training needs with them”. The manager advised that the local health team offer training, which the staff at the home can access. Reference material relating to health care of the residents was available in the nurse’s office. The manager and owner confirmed all mandatory training time is paid for staff. Health professional comment cards received praised the professionalism of the staff team at Kings Acre. Two health professionals comment cards received made the following written comments, “cheerful staff and good quality care”, “My impression has always been that Kings Acre staff are highly skilled and experienced and motivated.” Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good, 31,33,35,38 This judgement has been made using available evidence including a visit to this service. The resident’s benefit from the managers clear leadership of the home, which tries to ensure that the home is run in their best interests. EVIDENCE: The manager of King Acre has changed since the last inspection. She is a first level registered nurse who has achieved an NVQ 4 in management in August 2005. The manager had worked at the home for several years as the deputy manager prior to taking up her appointment. The training completed since the last inspection was discussed with the inspector. There are clear lines of accountability with in the home and staff work well together. One Health professionals comment card received made the following written comment. “ I Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 22 feel Kings Acre treats all the residents as “personal family members.” “There is strong evidence of their knowledge of residents preferences, likes and dislikes and they do go to considerable effort to meet these needs, often over and above what might be considered reasonable. This is due to good leadership.” The manager provided the results of the annual quality review for inspection. This showed that the residents and their representatives had high regard for the facilities and services provided at King Acre. The results were available for the residents. The manager advised that the results of any quality audit are shared with the residents their families and staff. The manager also provided an analysis of the staffing numbers provided against the dependency of the residents. These figures evidences that the number of staffing are decided in relation to the care needs of the residents on a weekly basis. When new policies have been introduced the manager has informed the Commission. A new risk assessment management policy had been developed in December 2006. Policies and procedures were available for inspection and easily available for staff. The date when existing polices and procedures had been reviewed was provided with the pre inspection information. How residents are encouraged to manage their own affairs as long as possible was discussed with the manager. A system of billing the residents or their representatives for hairdressing, chiropody and other services has reduced the need for residents to hold cash. The manager advised that those residents who are assessed as able could continue to manage their money if this is their wish. However at the time of this inspection none of the residents were able or had chosen to manage their own affairs. The manager confirmed that resident’s families or representative help the residents with their financial affairs. The record of cash being held for safe keeping for one resident was seen. The records of expenditure were recorded. The record of money held was the same as the money held for that resident. The manager confirmed that individual residents money is stored and recorded separately for each resident. Clear supervision records were provided for staff. Those staff asked said they received regular supervision and felt able to discuss their work with their manager. The manager provided information about the maintenance and health and safety services completed. A tour of the home revealed that hoist had been serviced and fire extinguishers checked as expected. Environmental risk assessments have been completed and where risk had been identified guidance provided to reduce the risk. These included hot water temperature for hot water in hand wash sinks in resident’s rooms. Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 23 A written statement of the health and safety management of the home was available for staff and residents on request. The inspector was told that all staff receive regular up dates for manual handling fire prevention, first aid and food hygiene. The staff records viewed supports this. The staff spoken to during the inspection told the inspector that they had recently had manual handling and fire awareness training. Residents whose care was followed had manual handling risk assessments completed as part of their plan of care. The manager provided the accident record book. This recorded the type of accident or incident and the actions taken following the incident. The manager advised that the individual residents name was kept separately from the accident record and recorded in their plan of care. Information was also provided regarding reportable incidences, this gave staff the information they need regarding what type of incident should be reported and how to report it. Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 24 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 4 3 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 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 4 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 3 X 3 Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard Good Practice Recommendations Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP 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 Kings Acre DS0000003591.V324368.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!