Inspection on 25/07/07 for Maple House

This inspection was carried out on 25th July 2007.

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

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

Other inspections for this house

Maple House 03/11/06

Maple House 28/09/05

Maple House 07/04/05

Maple House 20/10/04

Maple House 28/06/04

Maple House 03/03/03

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Manor House Nursing Home 23 Manor Road Aldershot Hampshire GU11 3DG Lead Inspector Tracey Horne Unannounced Inspection 25th July 2007 09:30 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 DS0000012151.V341558.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. DS0000012151.V341558.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor House Nursing Home Address 23 Manor Road Aldershot Hampshire GU11 3DG 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) 01252 325753 01252 341963 Dr Zyreida Denning Mrs Lindsey Virginia Long Care Home 34 Category(ies) of Dementia (6), Dementia - over 65 years of age registration, with number (34), Old age, not falling within any other of places category (34) DS0000012151.V341558.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the DE category can only be admitted between the ages of 55-65 years. 3rd November 2006 Date of last inspection Brief Description of the Service: Manor House is a nursing home able to accommodate 34 service users. It is situated off of one of the main roads into Aldershot. The service offered is for older people with mental health frailty and nursing needs. The accommodation is offered over two floors with two lounge areas and a separate dinning room, seating is also available in the conservatory. The home has a garden area accessed from the conservatory, which has seating available. Mrs Long confirmed the fees per week range from £520.00 - £700.00 per week. DS0000012151.V341558.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards (NMS) and Regulations. The findings of this report are based on several different sources of evidence. These included: an unannounced visit to the home, which was carried out on the 25th July 2007 between 09.15 and 15.30, during which the inspector (Mrs Tracey Horne) had the opportunity to speak with residents and staff, view records and procedures and talk to Mrs Long. Observations were made regarding the interaction between residents and staff and the care provided. The people living in the home prefer to be referred to as residents, therefore the rest of this report will reflect this. Mrs Long returned the Annual Quality Assurance Assessment (AQAA) prior to this visit and the Commission for Social Care Inspection (CSCI) sent surveys to residents, relatives or staff. The findings of the surveys are included in this report. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the CSCI. What the service does well: The home is good at assessing if it can meet the needs of residents before they come to the home. Residents said that the activities provided by the home meet their needs. Residents are provided with a warm, homely accommodation that they said meets their needs. Residents benefit form staff that are skilled and knowledgeable about the care needs of older people and regular training was available to them. Residents and staff said they have a good rapport with Mrs Long and she runs the home in their best interests. DS0000012151.V341558.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. DS0000012151.V341558.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 DS0000012151.V341558.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): 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives have the information needed to choose the home that will meet their needs and have their needs assessed prior to receiving residential. The home does not provide intermediate care. EVIDENCE: The AQAA states that six residents have been admitted in the last twelve months making a total of thirty-two residents living at the home. Mrs Long confirmed that pre admission assessments were carried out, four records were seen which had been signed by the resident, their relatives and Mrs Long and were dated. Mrs Long had visited the prospective resident to complete the home’s pre admission assessment before a place was offered at the home and said this usually occurs in the residents home or whilst they are in hospital and may co-insides with a care manager assessment. This was to ensure the home could meet their individual needs before the placement being offered. The DS0000012151.V341558.R01.S.doc Version 5.2 Page 9 resident’s family were involved and provided further information. Mrs Long said prospective residents and their families/ representatives are welcome to look around the home to see if the home would meet the individual’s needs. The pre admission assessments included a moving and handling assessment, medical history, allergies, history and risk of falls, equipment needed, personal care needs, personal preferences, medication and any anxieties etc. Feedback from residents and relatives stated that they had received information from the home, which enabled them to decide that they wanted to visit the home to view the facilities and environment. Two relatives stated in there ‘have your say about CSCI surveys: ‘I usually receive information about the home which enables decision making’. ‘My relative has settled very quickly and is very happy and comfortable.’ Mrs Long said the home do not provide intermediate care. DS0000012151.V341558.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): 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 receive health and personal cares based on their individual needs and are treated with dignity and respect whilst their privacy is maintained. Medication practices in the home are managed well. EVIDENCE: The AQAA states that resident’s individual health and personal care needs are met. Regular audits are carried out on care plans and medication stock and Medication Administration Record (MAR) sheets. All residents are treated with dignity and respect. ‘Have your say about’ surveys: ‘The manager is very capable and appears to be continually assessing the needs of residents to ensure these needs are met by staff.’ ‘The care given is very good and ‘usually’ as we expect or agreed.’ ‘There should be more attention to the person’s personal needs despite, perhaps the persons aggression.’ ‘The GP is always called if there is a problem.’ DS0000012151.V341558.R01.S.doc Version 5.2 Page 11 ‘Spectacles are not always on my relative and their call bell is often on the floor or where it cannot be reached.’ Mrs Long acknowledged this. During a tour of the home all residents seen (which included residents who were in their bedrooms) had access to the aid call pull cord. Four Care plans seen had been reviewed regularly and included information to enable staff to provide the exact care the individual needs. Dementia care observation records were seen to show progress. A ‘map of life’ included the individual’s previous employment, school, memories, interests, holidays and wishes for the future. Staff said this provides information so they can chat to residents about which is interesting. Care plans included guidelines for staff to follow if a person becomes agitated, staff said the guidelines need to be person centred as needs differ, and acknowledged that sometimes it may appear that they are dealing with the aggression to minimise escalation and risk to other residents and staff. One moving and handling assessment stated that two staff are needed to transfer but there was no record of this in the care plan, although when asked, staff said they were aware that two staff are needed. Mrs Long acknowledged this and updated the care plan. Nutritional assessments and Waterlow pressure sore assessments a=had been completed in all care plans seen. The majority of the care plans were person centred but some have yet to be completed. Records showed residents had accessed a chiropodist and their Doctor. The medication procedure was observed and medication was stored securely in the home- this included controlled medication. It was well organised into individual sections for residents. Staff confirmed that one trained nurse administers medication. Records of administration were complete and were also in place for controlled drugs and correct procedures, where sampled, had been followed. Staff said they receive training in the safe administration of medicines, certificates confirmed this. Mrs Long confirmed she completes regular audits surrounding medication practices. The inspector observed that staff were attentive, caring, respectful and they have a good understanding of each resident’s individual’s needs. Throughout the visit, staff were seen to knock on doors and wait before entering rooms and they spoke to residents in their preferred manner, as stated in their care plans, and were friendly but respectful. Staff said they are aware of the importance of dignity and respect. Staff induction records showed that privacy and dignity and the provision of personal care are covered during the induction process, and the response from residents indicated that staff treat them with dignity and respect and that they are trustworthy. ‘Have your say about’ survey: ‘the residents are treated with respect, they are involved in decision making-choosing clothes, necklace etc.’ DS0000012151.V341558.R01.S.doc Version 5.2 Page 12 DS0000012151.V341558.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): 12, 13, 14 & 15. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to exercise control over their lives, participate in social activities, receive visits from friends and relatives as they wish and enjoy a choice of meals served in a relaxed atmosphere. EVIDENCE: AQAA states: A Programme of activities includes: indoor golf, outings to local shops & pubs. Parties such as street, Christmas and Halloween. Residents said they are able to exercise choice by participating in social activities if they wish and their preferences are identified during the assessment process. This information is included in the individual’s care plan, therefore staff are aware of what residents like doing and records are completed to show activities participated in. During the inspection residents were chatting with staff and each other (there was a carer in each of the communal areas with residents). All residents stated the activities matched their needs, and that staff respected their wishes to spend time on their own if they wanted to. One survey stated ‘Not enough variation in activities. Mrs Long said she receives feedback from residents, staff DS0000012151.V341558.R01.S.doc Version 5.2 Page 14 and relatives to evaluate activities. An activities plan was displayed in a communal area which detailed: news discussion, hairdresser, visit to the local town, movement to music, BBQ lunch, bingo, sherry morning (every Friday, reminisance work, sing along, karaoke, pet therapy (and the home have a cat) and shopping and pub. Mrs Long said the home celebrate special dates such as Mothering Sunday, St Patrick’s Day etc. One relative stated in their CSCI survey that ‘Hair care, toe nail treatment is always carried out on a regular basis.’ Staff said they encourage residents to choose items of clothing, what they wish to eat (residents are fully involved in planning a menu for breakfast and supper). A resident chairs the residents’ meetings and one relative stated ‘I am always involved with decision making with regards to my relative.’ The home has an open visiting policy, this was evidenced by records of visitors to the home and confirmed by residents and relatives who stated they visit the home at different times of the day on a regular basis and are always welcomed. We observed refreshments being offered throughout the day for residents, the lunch consisted of two choices of a main course and a dessert, followed by tea or coffee. Lunches are cooked at another home owned by the provider and are transferred to Manor House in a trolley which ensures the food is kept hot. Mrs Long said that although there is a rolling menu, if changed and another meal is provided instead, she is not always told what the alternative option is, and cannot inform residents until the food arrives. Breakfast, tea and supper are cooked and prepared in the homes small kitchen. Homemade cakes are stored in the freezer in the garden shed (used to store freezer, a fridge and dried food stock). The temperature of the freezer was checked and was four degrees above the recommended maximum temperature, the fridge was also checked and was found to be two degrees above recommended maximum temperature. Staff said that the thermometer was broken, but it was stored in the freezer and may have been used to check daily temperatures (records of which were available.) Packets of dried fruit and brown sugar, which had been opened were not stored correctly and had attracted ants. Staff were asked to throw away the contents of all items that were opened and not appropriately stored in airtight containers. One open packet of vegetable suet stored in the fridge was out of date, again this was removed and discarded. A requirement was made to ensure satisfactory standards of hygiene are maintained. The manager asked staff to action this immediately. The area was checked before the end of this inspection and was found satisfactory. DS0000012151.V341558.R01.S.doc Version 5.2 Page 15 Residents and relatives were generally pleased with the meals provided, comments received included: ‘Residents are well fed.’ ‘The meals are sometimes slimy and I would like a change in diet.’ One resident asked the manager if they could have fish (in batter instead of breadcrumbs) and chips on a Friday. Mrs Long said she would speak to the chief of the other home. One resident said ‘Drinks are available all day, in hot weather lollys and icecream is given out.’ DS0000012151.V341558.R01.S.doc Version 5.2 Page 16 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. Residents and staff are confident that their complaints will be listened to, taken seriously and acted upon. Staff have a good understanding of Adult Protection issues to fully protect residents from potential abuse. EVIDENCE: AQAA States: One complaint was dealt with and resolved within twenty-eight days and was upheld. ‘Have your say about’ surveys: ‘Sometimes clothes go missing.’ ‘More care over residents clothing as many times my relative has been wearing someone else’s clothes.’ Mrs Long said that she requests resident’s clothing is clearly marked with their name so that items can be identified and improvements have been made and incidents of missing clothes have reduced. One relative stated: ‘Aware of how to make a complaint and would contact social services if necessary.’ Residents spoken with said that they were very aware of the complaints procedure, even though they have not had to use it. They said they would go straight to Mrs Long if they had a concern or complaint and were confident that Mrs Long would take their concerns seriously. Residents confirmed that the staff listen to them but one resident said that sometimes staff do not understand what is being asked. This was discussed DS0000012151.V341558.R01.S.doc Version 5.2 Page 17 with Mrs Long who will look into this matter. The complaint log was available which included sufficient detail to monitor complaints effectively. Staff said they were aware of the correct procedures to follow if a disclosure of abuse was reported to them, and they had received training in abuse awareness, certificates confirmed this. The home has procedures for staff to follow should abuse be suspected, including Hampshire County Council’s Protection of Vulnerable Adults and Whistle Blowing. All of the staff records seen showed that the appropriate level of Criminal Record Bureau (CRB) had been completed prior to the carer commencing their role. Mrs Long confirmed that policies and procedures are reviewed and available for staff to access regarding complaints and protection, staff confirmed this. DS0000012151.V341558.R01.S.doc Version 5.2 Page 18 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 good. This judgement has been made using available evidence including a visit to this service. The environment continues to be improved to provide residents with a warm and comfortable home. There are good infection control procedures at the home to safeguard the welfare of residents. EVIDENCE: AQAA states: Planning permission has been approved for kitchen & laundry extensions. Improvements have been made to replace the majority of soft furnishings in the home. The home would benefit from a larger kitchen to enable lunch to be prepared and cooked on the premises. The laundry is adequately equipped but very small. As planning permission has been granted to extend the kitchen and DS0000012151.V341558.R01.S.doc Version 5.2 Page 19 laundry, a requirement was not made on this occasion but this area will be looked at as part of future inspection. Mrs Long said that building work is due to start in four weeks time and the home will be decorated throughout and a new conservatory will be built. The home was warm and comfortable, residents confirmed this is always the case. One resident stated in their CSCI survey that ‘There is a relaxed homely atmosphere.’ Residents said they have their own personal belongings in their bedrooms, most of the bedrooms were seen Mrs Long explained that one person is employed to maintain the building. A maintenance record shows dates when faults were notified and when they were actioned and by whom. Staff said they have noticed improvements in the time it takes for jobs to be completed. Residents said they like spending time admiring and sitting in the garden, which is well maintained. The home was clean and Infection control procedures were in place. Staff were observed to follow this guidance, equipment such as gloves and aprons were available and the home have a contract with a clinical waste company to ensure bins are emptied regularly. DS0000012151.V341558.R01.S.doc Version 5.2 Page 20 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. Staff in the home are trained, skilled and in sufficient numbers to fill the aims of the home and meet the changing needs of residents. Recruitment practices ensure resident’s safety. EVIDENCE: AQAA states that thirty-four staff are employed, six are ancillary staff. 50 of staff are working towards NVQ 2 or above. All staff who have been employed in the last year have had satisfactory pre-employment checks. Mrs Long confirmed that there is always one trained nurses on duty day and night with four care staff and separate ancillary staff to carry out cleaning, laundry and cooking. ‘Have your say about surveys: ‘Staff are ‘usually’ skilled and experienced to look after residents properly.’ ‘As a frequent visitor there are usually plenty of staff of various levels to cope with resident’s needs.’ ‘The staff are very caring and supportive to my relative and my family.’ It was evident from practices and interactions observed that staff had developed a good relationship between themselves and residents. Comment from residents included that staff were kind, friendly and helpful. DS0000012151.V341558.R01.S.doc Version 5.2 Page 21 One resident said ‘I do feel we have to wait a long time sometimes.’ The aid call alarm was tested and staff responded swiftly. Staff said the recruitment process within the home are thorough, so too was the induction programme. Staff files were seen and included pre employment checks needed to ensure the persons identification. CRB records showed that the checks had been completed after the person had been confirmed in post. Staff training files showed that they had received training in the Mental Capacity act, enhanced clinical practice, incontinence, Parkinson’s disease, end of life, syringe drive in palliative care and medication, all of which staff say equip them to support individual residents as their needs change. All records seen showed that staff have received training in mandatory training such as moving and handling, first aid and COSHH. DS0000012151.V341558.R01.S.doc Version 5.2 Page 22 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 Good. This judgement has been made using available evidence including a visit to this service. The manager is experienced and competent to run the home. Management and administration of the home is based on openness and respect. An effective quality assurance system is in place. Resident’s finances are safeguarded by the home if residents prefer. Residents’ health, safety and welfare are promoted and protected within the home. EVIDENCE: AQAA states that questionnaires for residents, staff and visitors are circulated to gather views and opinions. All service, equipment and safety equipment/appliances have been serviced or tested. COSHH assessment in place. All policies and procedures are in place. DS0000012151.V341558.R01.S.doc Version 5.2 Page 23 Mrs Long is registered with the CSCI. One relative said the manager is very capable. Mrs Long has made many improvements since commencing her post, as mentioned throughout this report. Residents and staff said they were confident in Mrs Long’s ability. The staff felt they were included in the day-to-day decision making within the home, stating that changes and or issues are discussed and actions agreed at regular staff meetings that are minuted. A robust quality assurance and monitoring system based on seeking the views of residents, relatives and professional is in place. The most recent findings were seen. Relatives and residents were generally satisfied with everything. Resident said if they are not happy with something, all they need to do is tell someone, and it will be seen to. Mrs Long said that unannounced visit by the service provider [Regulation 26 visits] occur on a regular basis, records of these visits were available. No unsafe practices were observed during the inspection. There is an ongoing system in place that ensures that all appliances are serviced, records and certificates seen indicated that the systems such as the electrics and specialist equipment including hoists receive regular servicing and maintenance. The employer’s insurance liability certificate was displayed and current. Risk assessments where necessary have been completed. Staff have received training in health and safety, first aid, fire safety, control of substances hazardous to health and moving and handling. The fire drill records showed that all staff had attended two fire drills in the last year as well as fire training every six months. Checks of all fire safety equipment had been completed regularly. The home has a satisfactory reference file for the Control of Substances Hazardous to Health (COSHH) information leaflets for each chemical being used in the home. The home has a policy, procedures and information on health and safety. A sample of policies and procedures were seen that are reviewed regularly. DS0000012151.V341558.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 X X 3 X X 3 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 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 DS0000012151.V341558.R01.S.doc Version 5.2 Page 25 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 OP15 Regulation 16.2 (j) Requirement The manager must consult with the environmental health authority and ensure all food items are stored satisfactorily. Timescale for action 29/08/07 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 DS0000012151.V341558.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 DS0000012151.V341558.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. 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