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Inspection on 17/08/07 for Plane Tree Court Care Village

Also see our care home review for Plane Tree Court Care Village for more information

This inspection was carried out on 17th August 2007.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The manager ensures that people and their relatives are confident that the appropriate level of care and support will be provided, and people said ` Dignity is respected, communication is excellent,` and `things are dealt with promptly.` The quality of life in relation to activities and community presence is good and promotes independence and emotional wellbeing. Staff are experienced and caring, are interested in people and promote wellbeing by treating them with dignity and respect. The manager knows what she needs to do to improve the service. she understands and is honest about what still needs to be done. This shows

What has improved since the last inspection?

Ross House is being extended and modernised, this process is well underway and when completed all areas will be clean and free from offensive odours. People were satisfied that `large-scale building renovations are in progress and when completed should provide a pleasant environment`. Newly appointed staff now undertakes the Skills for Care common induction program within six months of coming into post. Criminal record checks were in place for staff however the manager must ensure that she follows guidance for good practise in this area for staff who move from one part of the organisation to another or whose role changes substantially. The protection of vulnerable adults procedure has been updated and staff training has been organised. Food preparation and choice at Ross House has improved and the kitchen has been deep cleaned. Fire checks are now generally completed weekly, however the manager should ensure that, in the absence of the person who carries this out, the task is reallocated.

What the care home could do better:

Monitoring and accurate updating and review of care could be achieved through revision of the way information is recorded and stored. Assessments should include more detailed information about people`s social histories and their interests and aspirations. This will help staff provide more consistent care. The registered person should develop the recording in the complaints book ensuring that staff complete the record and are aware of what constitutes a complaint and record the action taken. This will demonstrate that the manager does listen to complaints and acts on them.

CARE HOMES FOR OLDER PEOPLE Ross House 11 St. Lesmo Road Edgeley Stockport Cheshire SK3 0TX Lead Inspector Michelle Haller Unannounced Inspection 17th August 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 Ross House DS0000008587.V349302.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. Ross House DS0000008587.V349302.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ross House Address 11 St. Lesmo Road Edgeley Stockport Cheshire SK3 0TX 0161 480 6919 0161 286 3175 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) Altruistic Care Limited ** Post Vacant *** Care Home 44 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (5), Old age, of places not falling within any other category (44) Ross House DS0000008587.V349302.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 44 OP and up to 5 MD (E). Date of last inspection 12th March 2007 Brief Description of the Service: Ross House is a large, detached building set in its own grounds in Edgeley, a suburb of Stockport. There are local amenities situated close by. Altruistic Care Limited owns the care home. The directors of the company are Mr and Mrs Jivraj. The owners visit the care home on a regular basis and Mr Ken Thomas carries out the Regulation 26 visits on behalf of the registered person as defined within the Care Home Regulations 2001. The care home is on four floors, with a passenger lift to assist service users to mobilise to the upper floors. Lounge and dining areas are situated on the ground floor with an additional lounge on the first floor. The home is undergoing a massive refurbishment and having an extension built. The home currently accommodates a maximum of twenty-eight service users to ensure they are not inconvenienced by the building work. The CSCI inspection report is available on request. The fees for staying at the home were reported to be between £315 and £500 per week. Ross House DS0000008587.V349302.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection, which included a site visit to the home, was completed over a period of nine hours. The manager was not informed beforehand that we were coming to do an inspection. Information was gathered from looking at the care for six people living in the home and examination of other correspondence and reports concerned with providing care and running the home. People and their relatives were interviewed and the interactions with staff observed. Procedures that were carried out were observed and a tour of the building was undertaken. Information received prior to the inspection was also taken into consideration. Five service user surveys and five relatives surveys were returned to the Commission. The manager also completed and returned the CSCI Annual Quality Assurance Assessment. This asks the manager to tell us what they think they do well, what they have improved and what they need to do better. We use this information throughout the inspection process. What the service does well: The manager ensures that people and their relatives are confident that the appropriate level of care and support will be provided, and people said ‘ Dignity is respected, communication is excellent,’ and ‘things are dealt with promptly.’ The quality of life in relation to activities and community presence is good and promotes independence and emotional wellbeing. Staff are experienced and caring, are interested in people and promote wellbeing by treating them with dignity and respect. The manager knows what she needs to do to improve the service. she understands and is honest about what still needs to be done. This shows Ross House DS0000008587.V349302.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. Ross House DS0000008587.V349302.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 Ross House DS0000008587.V349302.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 (NMS 6 is not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People moving into the home have their needs assessed prior to their admission that ensures that the manager is confident the staff have the skills to meet residents needs. EVIDENCE: Each care file that was examined held assessments that identified health and physical care needs, including moving and handling, some social history and interests, and an assessment of dependency was also in place, clearly detailing the level of support required in activities such as personal care, eating, maintaining continence. The most recent admission also had a completed preadmission checklist on file. Ross House DS0000008587.V349302.R01.S.doc Version 5.2 Page 9 People who returned surveys all felt that they were given plenty of opportunity to get to know about the home before becoming a permanent resident They also felt that the manager had made sure they their needs could be met before agreeing to the admission. Comments included: ‘I had a six week trial before deciding to make the move to Ross House permanent.’ And ‘Full viewing facilities afforded by Ross House to all parties and all questions answered fully.’ Ross House DS0000008587.V349302.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning process at Ross House continues to be developed and people in the home have their health and personal care needs met with dignity and respect. EVIDENCE: The care files examined contained care plans that reflected peoples assessed needs and provided staff with information about how these needs were to be met and the outcomes that were expected. Although the information needed to be gathered from different places, there was clear documentary evidence confirming that routine and the relevant professionals including, opticians, district nurses, podiatrist, dieticians, speech and language therapist and general practitioners completed specialist health care and checks. Specialist assessments including falls risks, pressure area and skin integrity assessments, nutritional state and communication had been completed. Ross House DS0000008587.V349302.R01.S.doc Version 5.2 Page 11 Some records and assessment were particularly good, for example the description and care plan for someone with difficulties sleeping was exemplary, highlighting the possible reasons for the problem and providing staff with step by step instructions about providing the best environment that may assist this person to settle. Night sedation was also monitored to ensure that this medication was used only if strictly necessary once the care plan and night routine was fully established. This assessment and plan was ‘person centred’ and this method of assessment and care planning should be developed for each person. Six files were looked at and dates and signatures confirmed that care plans were reviewed and updated although in 2 cases the details did not relate in depth to the complex needs of the people. Discussion took place with the manager regarding identifying and recognising when a total review of care, reassessments of needs and development of a new care plan may be required. Monitoring of skin integrity is detailed and to a good standard- the staff now need to be consistent in demonstrating that action is taken to deal with problems that come to light. People who returned CSCI surveys felt that they always received the medical and health attention they required. People who commented were satisfied with the health care provided in the home and reported that ‘doctors come and see her.’ And ‘Yes I have had the doctors and I’m just waiting for an opticians appointment.’ Certification and notices indicated that staff have received training in providing health care including dementia care, dealing with swallowing problems and using the homes medication system. The medication storage and administration systems were examined and were in the main satisfactory. Medication is provided in a metered dosage system. The Medication record sheets were examined and no gaps were noted. The only issue is that the dates did not tally in that staff started each new sheet on the 1st despite the actual date. This issue was discussed briefly at the time of the inspection. Observations of the interactions between staff and people using the service confirmed that people were treated in the main, with dignity and respect, and their privacy respected. However we did note there were times when staff appeared uncertain about the approach they were to have with some people and so were inconsistent in their response. This links in with a lack of detail and information in some care plans; in that staff have not been provided with sufficient instructions in how to meet the complex needs of some people. Ross House DS0000008587.V349302.R01.S.doc Version 5.2 Page 12 At other times staff were seen to be very attentive in their approach and were concerned in meeting the needs of people diligently and with patience. Daily reports and the communication book were read through and these were written in a respectful manner and together provided a good picture of the health and personal support provided to individuals in the home. In the main people who returned CSCI surveys were positive about staff attitude and felt that they were kept informed about the progress of their relative. Comments about staff attitude included ’I have seen the staff with more ‘demanding’ people and they are always patient and kind.’; ‘They treat (people) lovingly.’ Ross House DS0000008587.V349302.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Ross House are able to make choices about their lifestyle and are supported to develop and maintain life skills, and activities appear to meet the expectations of people in the home. EVIDENCE: The activities calendar displayed in the home indicated that people could choose from a variety of activities daily. Activities organised on the premises included; discussing article in the local news paper, exercises routine called ‘healthy hearts and hips’, bingo, hand and nail care, baking, floor basket ball, arts and crafts, giant floor games and parties commemorating key dates and anniversaries. Activities in the local community includes opportunity for people to regularly attend a luncheon club, a tea dance, church services on a weekly basis, outings to the War Museum in Salford, a visit to a local garden centre and daily walks to the park to watch and join in at a local bowling club situated in a nearby park. Pictures were on display in the home recording the activities that had taken place and paintings; drawings and other artwork were also Ross House DS0000008587.V349302.R01.S.doc Version 5.2 Page 14 displayed. Almost every one who was spoken was enthusiastic about the activities and no one said that they were bored. Staff also stated that they had recently completed a 10-week course in providing activities for people living in residential homes. During the inspection a game of ball was observed and at least eleven people participated and appeared to enjoy the game. This aspect of the service could be further improved if social histories and past and present interests were completed in more detail, so that activities provided could be more individualised and person cantered. Comments about activities included: ‘I like the activities- I did a nice drawing and we went to the garden centre- I really enjoyed it.’ ‘She is encouraged to join in with activities and outings- she is not forced.’’ There’s always something to do- no chance of getting bored.’ The routine in the home appears flexible and people were able to choose what they wanted to do. Staff commented that people could choose what time to go to bed and get up; meals could be taken in their bedroom if they wished, but most people preferred to spend time in the lounge areas unless they were receiving visitors. It appears that people are encouraged to receive guests at their leisure, and all respondents felt that they were always made welcome. During the inspection it was observed that relatives and friends could visit freely. Comments included: ‘I can drop in anytime and I’m welcomed with a drink.’ ‘No problems visiting the home whatsoever.’ The meal on the day of inspection was fish and chips or sausages and chips the soft diet was appropriate. Mealtime was observed and in the main this was a pleasant experience with people provided with support to maintain their independence with dignity and respect. The dining areas were clean and chairs and tables were free from unpleasant stains. It was also noted that staff were aware of food preferences and referred to people in a fond and friendly manner. The menus indicated that breakfasts were generally cooked with a choice of cereals, lunchtime meals a good variety of casseroles, bakes and stews and roasts and teatime was generally a hot choice or sandwiches. The cook was aware of people who required additional nutritional fortification and described the steps she would take to meet special dietary needs. Comments about the food were generally positive with most people saying there had been a recent improvement, although one person felt that standards Ross House DS0000008587.V349302.R01.S.doc Version 5.2 Page 15 in this area had decline. People said: ‘ ‘The food is lovely.’ ‘If …didn’t like the food she would say.’ And ‘Mum says the food seems to have gone down a bit.’ On the day of inspection people were observed enjoying their meals and comments heard were positive such as ‘I love fish.’ Ross House DS0000008587.V349302.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were confident that concerns and complaints would be listened to and acted upon. EVIDENCE: Discussion with the manager and information received prior to the inspection confirmed that complaints were dealt with appropriately. Discussion took place with the manager regarding how she records complaints brought to her attention, and that it is good practice to record all concerns and complaints no matter how small. The manager stated in the AQAA that a complaints procedure was in place and people who returned surveys felt that their concerns were dealt with most of the times, and all knew the procedure on how to complain. Comments related to complaints and concerns included: ‘If I have any problems I can always approach the manager for her assistance.’ ‘I would complain to the rest home manager.’ And ‘When I raise any issues with the manager they are dealt with immediately.’ The manager stated that no investigations under the Protection of Vulnerable Adults had taken place in the home since the last inspection and the manager Ross House DS0000008587.V349302.R01.S.doc Version 5.2 Page 17 stated that they have reviewed the home’s adult protection policy to be in line with the guidance provided by Stockport Council. Training records indicated that staff have received this training and those who were interviewed had some understanding of the behaviours that could be considered as abuse. Statements concerning the behaviour of staff were all positive and complimentary and included: ‘From what I see my mother is very happy at Ross House, the staff are very nice with all the residence.’ Ross House DS0000008587.V349302.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The provider is working to further improve the home with an extensive refurbishment underway which will enhance the environment for people living and working there. EVIDENCE: A tour of the home was completed. People were observed mobilising around the building safely using equipment and adaptations that are in place, including grab rails, heightened toilet seats, frames and walking sticks. The lounge area and dining areas are large although sound does travel between the two sitting areas and so it can become quite noisy and confusing when both televisions are showing different programmes. Ross House DS0000008587.V349302.R01.S.doc Version 5.2 Page 19 Bedrooms were entered and these were in the main clean and many had been personalised. The front corridor holds a bad odour and this has been commented on in previous reports and by people who returned CSCI surveys. The manager said she is aware of this, as is the provider, and they are working on a deep cleaning regime for this area. A tour of the refurbished part of the home was also undertaken and this indicates that people will be able to enjoy a greatly improved environment, in that all bedrooms have en-suite shower rooms installed and the size of the rooms are larger than those currently available. These rooms are also decorated to an excellent specification and the lounge areas will be separate. Ross House DS0000008587.V349302.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In the main staff are available in sufficient numbers and skill mix to meet the needs of people in the home. EVIDENCE: On the day of inspection there were 27 people living at Ross House, and 10 members of staff including the manager and four care assistants. Staff were observed having time to spend time with people on an individual basis. The manager stated that the majority of staff had achieved National Vocational Qualification (NVQ) in Care level 2 or above and recent recruits have been enrolled onto the course. The manager stated that she was in negotiation with the local authority, college and other organisations in relation to accessing staff training. Certificates and the training records indicated that staff training had included: Health and safety awareness; dementia care level 1 and 2; first aid, food hygiene, care for elderly with diabetes, control of substances hazardous to health (Coshh) and stage one and two infection control. Ross House DS0000008587.V349302.R01.S.doc Version 5.2 Page 21 The main training needs concerned moving and handling and POVA training. The manager was able to confirm that a training day for all staff had already been agreed in relation to POVA alerters. The manager is a moving and handling facilitator and confirmed that she was planning to provide this training in house. This training should also be prioritised and the manager must be able to demonstrate that a person who is suitably qualified provides moving and handling training to an acceptable standard. Supervision records were in place and these confirmed that the manager was currently instructing staff about her expectations in relation to the standard of care and philosophy and ethos in the home. Staff stated that they enjoyed working in the home and felt encouraged to improve and learn new skills. Comments included-‘I enjoy coming to workhave completed the induction booklet and was encouraged to begin NVQ 2.’ A selection of recruitment and employment records were examined. Each continued a copy of a Criminal record bureaux (CRB) check completed by the company, two reference and the completed application forms were also in place. Additional proof of identity was also on file. It was noted that when staff transferred from one part of the organisation to the other CRB’s were not repeated. This was discussed with the manager, and it was explained that any substantive change in post should trigger the request for a new CRB for example changing from being employed as a care assistant to being employed as a registered nurse. Ross House DS0000008587.V349302.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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has not yet been registered by the Commission, is relatively new to Ross House and is instigating changes and developments that will improve the care and support provided to people. EVIDENCE: The manager at Ross House is experienced and has worked for the company for a number of years. She has not yet been registered by the Commission to be the registered manager although this process is underway. There was ample evidence on the day of inspection to suggest that she competencies to manage the home and capable of identifying areas for change and Ross House DS0000008587.V349302.R01.S.doc Version 5.2 Page 23 improvement. The manager has also reaffirmed the importance of the procedures in the home, in particular fire safety and adult protection. Staff have received one to one supervision and people using the services have been invited to comment on the care provided on a one to one basis. The manager is also developing a questionnaire ‘Have your Say’ which will be rolled out in the coming year. This shows the manager to be open to ideas and willing to listen. Staff commented that the management of the home is open and that they were encouraged by the positive changes in the home, not only to the environment, but also food provided and activities that were now available. In the main health and safety issues were managed appropriately although the manager must ensure that the responsibility for weekly fire checks is reallocated if the person who is usually responsible is unavailable. Fire safety training has been organised and the fire safety equipment checks were up to date. According to the information provided in the AQAA, the maintenance of other services and equipment such as the lift and electrics in the home had also been completed in line with the manufacturers guidelines. The only omission concerned the movable hoist, it is good practice to service this piece equipment every six months and this was brought to the managers’ attention. Although staff had received infection control training, it is important that the manager and senior staff consider introducing clear guidelines to reduce the risks in respect of activities that could involve sharing implements and creams, for example manicures or hand massages. The home tends to differentiate between accidents and incidents and so all falls were being recorded as incidents. Although there was some indication that steps were taken to prevent the repeat of incidence this was not always clear because the information was not analysed and neither was it transferred into the person’s individual record. Furthermore it was difficult to track how an incident was resolved. These concerns were discussed with the manager. Money held on behalf of people is fully accounted for a selection of financial records was checked and each balanced correctly. There was also signatory evidence that the home had completed it’s own random financial audit. Ross House DS0000008587.V349302.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Ross House DS0000008587.V349302.R01.S.doc Version 5.2 Page 25 No 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. 1. Standard OP31 Regulation 8,9,10 Requirement The registered person must propose to the CSCI a manager for consideration for registration. Timescale for action 01/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The registered person should ensure that reviews and care plans provide information and instructions that relate directly to the current needs of individuals; this will assist staff in providing more effective and consistent support. The registered person must ensure that a record of complaints is maintained so that these can be used as part of the assessing the quality of the service. This will help to prevent problems being repeated. 2. OP16 Ross House DS0000008587.V349302.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Ross House DS0000008587.V349302.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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