Inspection on 17/07/06 for Royal Court

This inspection was carried out on 17th July 2006.

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

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

Other inspections for this house

Royal Court 20/02/06

Royal Court 12/10/05

Royal Court 14/03/05

Royal Court 17/11/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Royal Court Fiddler`s Green Lane Cheltenham Glos GL51 0SF Lead Inspector Nick Jones Key Unannounced Inspection 9:15 17th and 18th July 2006 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 Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 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. Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Royal Court Address Fiddler`s Green Lane Cheltenham Glos GL51 0SF 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) 01242 221853 01242 518827 Bromford Housing Group Mrs Susan Elizabeth Charlton Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (44), Physical disability (4) of places Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. A designated respite flat will be used to accommodate a named person who is under 65 yrs of age & who has a physical disability for periods of respite care. 12th October 2005 Date of last inspection Brief Description of the Service: This Care Home is purpose built and is divided into six units of self contained flats offering independent living for those over 65yrs of age with personal care available as required. The flats vary in size but all contain an inner lobby, bathroom, airing cupboard, lounge and kitchenette. There are communal dining rooms in each unit and one main lounge. A well-equipped hairdressing room is also on site. Communal bathrooms are equipped with specialised bath hoists and some adapted toilets. All doorways are wheelchair friendly. In addition there are two passenger lifts giving access to all floors. The forecourt, which has been planted with shrubs and flowers, can be enjoyed in the warmer weather. There is ample, level parking and the local bus route into Cheltenham Town runs outside the Home. There is also a local grocery shop nearby. The ranges of monthly fees are from £1418 to £1603. The home has a Statement of Purpose and Service User Guide that are offered to both residents and relatives. Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out by one Inspector between the hours of 9.15am and 2.00pm on 17th July 2006 and between 10.00am and 6.00pm on 18th July 2006. The Registered Manager and the Activities/Training Co-ordinator were on duty as were other members of the home team. Four staff were spoken with and a staff shift handover was observed. A tour of the building including all communal areas was completed; some individual flats were also viewed. Pre admission assessments were read along with a sample of residents’ care plans and other related care documentation. Chosen areas of the medication system were inspected, including related records. Lunchtime was observed and residents’ views on the food sought. A sample of records of staff recruitment and staff training were viewed. The general management of the home was inspected which included systems such as staff supervision and quality assurance. Arrangements for the safe storage and recording of residents’ monies were inspected. Health and safety records were also viewed. Six residents and two relatives were spoken with in detail, several others were asked their views on the food and how they spent their day. Two District Nurses attending the home were also spoken with. What the service does well: An informative brochure is available so that prospective residents and their families can learn about the home before choosing to live there. The home welcomes staying visits by prospective residents and their friends and family. This home provides both high quality private environments, as well as pleasant, well-equipped communal areas for the residents. A good standard of food is provided, with consideration being given to individual likes and dislikes. Residents are actively supported to remain in control of their own lives and to make choices for themselves. They are supported to express their views that are listened to and acted upon. Staff are well trained and supported in the work they carry out. The residents spoken to knew who to complain to and said the manager dealt with their concerns. Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 Page 6 A visitor spoken to said the home and staff were excellent and that the relative they were visiting was very happy living here. A resident stated the staff here are lovely and that the home is like a village. 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. Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 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 Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The information provided by the home enables prospective residents/relatives/sponsors to make an informed choice. The assessment procedures used by the home ensure residents’ needs are assessed and met. Intermediate care is not provided at the home. EVIDENCE: The home’s Statement of Purpose was seen in the reception area. This contains information about the Bromford Housing Group, Royal Court and outlines some of the group’s key policies and procedures. Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 Page 9 New residents are issued with a copy of the Service Users Guide as part of a ‘Welcome Pack’ given to them when they move to the home. This information is similar to the Statement of Purpose, but summarised and more specific to Royal Court. This includes a questionnaire that can be filled in two weeks after the resident has moved in to enable them to express any early thoughts or concerns about their life in the home. Residents spoken with confirmed they had been given this information. The home has an assessment flat available within the home for prospective residents to try out the home for themselves and for the home to continue their own assessment of the needs of a potential new resident. The pre admission assessments of need of the two most recent admissions to the home were read. These were well written and contained relevant details about a wide range of support needs and personal care. Appropriate care plans had been devised, generated from the assessments. The Manager or Deputy Manager always carry out the pre admission assessments. Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good with one aspect being considered adequate. This judgement has been made using available evidence including a visit to this service. The care records were detailed, well written and mostly reviewed monthly. Some care plans have not been reviewed with the involvement of residents. Healthcare professional support the residents and appropriate records were made of their visits. The system for medication storage and administration are good with clear and comprehensive arrangements in place to ensure residents’ medication needs are met safely. The service users spoken to felt they were treated with respect with individual flats for all service users providing ample opportunity for privacy. EVIDENCE: Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 Page 11 A selection of care documentation was read. All care staff record within this documentation and a ‘key worker’ group approach is taken when reviewing or writing care plans. Six care files were read in detail. The needs assessments and care plans of all residents have been updated since the previous inspection. There was evidence that most are regularly reviewed. The plans included details about how to support a person with support needs such as personal care, diet, health care, medication, mobility, and social interests. A member of staff is planning to run a poetry/literature appreciation group for some residents who have expressed a wish for such a group. The files also contained risk assessments for a variety of activities that are updated when the needs of residents change. One resident’s care plan stated that fluid intake must be recorded and monitored. Recorded details were not available for the last few months. The manager stated that this was because the health of the person concerned had improved and so no longer required detailed records. This had not been indicated in the care plan reviews. Discussions with residents and viewing care plans showed that some residents are involved in devising and reviewing their care plans but that others are not. All residents stated they would be able to discuss issues that were important to them with staff. One of the home’s quality assurance targets identified in March 2006 was to offer residents the opportunity to take possession of their own care plans. The care documentation demonstrated that residents were receiving on a regular basis, attention from a chiropodist, district nurses and their GP’s. A Community District Nurse and Student Nurse were visiting during the inspection to complete one of three regular visits they make each week to the home. Several residents require regular, planned visits for issues such as dressings that require changing. The District Nurse stated staff working at the home were good at communicating with them and will contact them if the needs of a resident changes. One resident stated the home was very good at organising a District Nurse and their GP to visit when they needed this. Their relative who was visiting during the inspection confirmed this opinion. The medication system was inspected in four separate locations. All were stored correctly and were organised with only the stock required at that the time being stored. Records were kept correctly with no gaps in administration. A selection of staff training files were inspected and certificates were seen in accredited training for medication administration. The Manager confirmed that all staff administering medication in the Home, hold appropriate accredited training. The self-contained flats provide ample space for privacy for residents. Several residents were receiving visits from friends or relatives during the inspection where the lounge area in each flat provided suitable space for several visitors Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 Page 12 at a time. Each flat contains a separate bathroom but residents are able to use other specialist bathing facilities should they need or choose this. Residents described staff being very kind and thoughtful in how they are looked after. Residents confirmed that the staff always speak to them politely and carry out any care tasks in private. Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good with one aspect being considered adequate. This judgement has been made using available evidence including a visit to this service. The residents have a varied activities programme, which meets their individual lifestyle needs. Suitable transport is not always available to support activities outside of the home. Residents are supported to maintain links with family, friends and the local community. Residents are supported to lead independent lives for as long as they can and to make their own choices. The meals in the home are good and aim to meet a wide variation in taste and dietary need. EVIDENCE: Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 Page 14 Discussions with residents showed the home is sensitive to the individual needs of residents in how they wish to be supported to in their daily living routines and activities. One resident described enjoying being able to choose whether to spend time in their flat or joining other residents in the communal areas for meals and planned activities. “It’s like a village.” New service users are asked what activities they enjoy and every effort is made to meet their needs. The activities offered by the home are advertised on a weekly basis on the notice boards in the dining rooms around the home. Activities offered include entertainers, dress shows, quizzes, health and beauty sessions, piano sessions and some trips out for shopping or days out. Residents and staff stated it was not easy to access vehicle transport for trips out, particularly for wheelchair users. Residents stated that family and friends are able to visit at any reasonable times. One resident stated they loved having their own space to entertain friends and family. Another resident stated their relative is able to visit every day. Some residents are individual members of Dial-a-Ride and others access social clubs outside of the home. One resident described enjoying being able to prepare their own snacks in their flat and that they were being provided with a fridge that can sit on a work surface to allow easier access. Another resident described using their own phone on a regular basis to maintain contact with their family. Residents bring their own furniture to their flats. One resident described how they liked having their own furniture around them. Residents stated the quality of food was good with choices of meals made available. Breakfast trolleys are taken to individual resident’s flats where they are offered a range of breakfast options. Drinks and snacks are also offered during the day. Residents stated they are able to eat in the communal dining rooms or in their own flats. One resident stated they chose to do both, depending on their mood. Lunchtime, in one dining room was observed during the inspection. The meal was served in an unhurried manner and residents present enjoyed the social occasion. One stated the liver was very tender and that the fruit crumble was excellent. The home produces a three-week menu with two main menu choices for each main meal. Residents stated alternatives are offered if they do not like the two main choices. Residents described attending a recent meeting with the cook and other staff allowing them to make requests and suggestions about changes to the menu. Some of these have been incorporated into new menus and residents were positive about the changes. Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. 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. There is a satisfactory complaints system, with evidence that residents feel that any concerns they may have are listened to and acted upon. The home’s Adult Protection policies help to provide a safe environment for the residents. EVIDENCE: There is a clear written and appropriate complaints procedure that is easily accessible to all in the home. Copies of the procedure are made available to residents when they move to the home and are also displayed in the entrance hallway. All residents spoken to confirmed that staff were very approachable, and were always ready to listen to any views they may have. They also stated they could always speak to senior staff if they wished. The home has a written policy on protecting residents from abuse, and has a Whistle blowing procedure for staff to follow if they had any concerns. Discussions with staff and training records showed the home provides the training and support to staff to best safeguard residents from the different types of possible abuse. Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 Page 16 Safe storage is available should any resident wish to place valuables with the home for safekeeping. There are clearly set out records of any monies held by the home on behalf of residents. Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good with one aspect being considered adequate. This judgement has been made using available evidence including a visit to this service. The home provides safe, well-maintained accommodation for residents to live in. The ventilation of ground floor bedrooms is insufficient. A homely and clean environment is provided for residents. EVIDENCE: A tour of the building was completed, but with only some of the flats being individually seen. The flats reflected the tastes and individual preferences of residents. The building appeared to be safe and well maintained. There is a rolling programme of improvements and re-decoration. Medication cabinets are Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 Page 18 in the process of being re-positioned in all of the bathrooms in the individual flats. Once this piece of work is completed there are plans to renovate and, in some cases, change the facilities available in each bathroom. Staff are responsible for checking the individual flats and write a report which is passed on to the maintenance worker who completes or co-ordinates the necessary works. If residents wish to have their flat decorated, they are offered another flat to stay in, although several residents do not want the upheaval and do not have their flats totally redecorated. The inspection was undertaken during a hot spell of weather. Portable fans were available for use by all residents and staff were very attentive and aware of residents need to keep as cool as possible. Residents with bedrooms on the ground floor complained that they are not able to keep their bedroom windows open at night due to security issues. Several complained that this was having a major impact on their quality of life. The need to find a solution to maintaining security but allowing ventilation in the ground floor bedrooms is a requirement of this report. The home was visited for an environmental health inspection in June 2006. The report was very positive about standards of hygiene with only two minor recommendations to action. The home was found to be clean, hygienic and free from odours. The home is cleaned to a good standard, with laundry and clinical waste handled appropriately for the prevention of cross infection. Gloves and aprons are provided for staff. Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27.28, 29 and 30 Quality in this outcome area is good with one aspect being considered adequate. This judgement has been made using available evidence including a visit to this service. Staffing numbers and skill mix are adequate to meet the needs of the residents currently living in the home. Recruitment procedures ensure that there are full and appropriate safeguards in place to ensure the protection of residents. The recruitment of one member of staff did not follow the procedures appropriately. The arrangements for the training and professional development of staff are good, enabling them to have an understanding of their roles. EVIDENCE: Staff duty rosters were viewed and showed there were sufficient staff to meet the needs of residents. Recruitment of a senior domestic member of staff is underway who will undertake the supervision of the three domestic staff working at the home. Additional staff have been recruited to provide an additional member of staff to work during the afternoon and evening. In addition to care and senior staff, the home has three domestics, a laundry assistant and maintenance man all working part-time. There is a full-time cook and assistant cook, with a part-time kitchen assistant. The home also has a full-time activities/training co-ordinator. Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 Page 20 There are five staff who are qualified to an NVQ level 2 or above in care, with ten staff working towards completing this award. Four staff are undertaking the level 3 award. The training co-ordinator is an NVQ assessor. Staff files were viewed and contained evidence that suitable recruitment procedures were being followed. The manager does not see the Criminal Records Bureau (CRB) checks undertaken by staff but receives a letter from the human resources department of the organisation confirming the disclosure number and conclusion of the check. The home had recently recruited an assistant cook from an agency where a CRB checks are not routinely undertaken for their staff. There was evidence that the home has now applied for both the POVAfirst and CRB disclosure. The manager stated the member of staff does not have direct contact with residents and works in a supervised capacity. It is a requirement of this report that all staff working at the home must have the appropriate checks completed before they commence in post to ensure the safety of residents. Staff training records viewed demonstrate that there are regular training opportunities for staff, with a range of training relevant to their roles being undertaken. New staff receive a structured induction using the Skills for Care format. A staff training matrix is maintained to ensure all staff receive mandatory training and refresher courses. Additional course have been provided in how to support people with MS, Parkinson’s disease and dementia. Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31.33,35, 37 and 38 Quality in this outcome area is good with one aspect being considered adequate. This judgement has been made using available evidence including a visit to this service. The home is run by an experienced Registered Manager who has worked at the home for many years. The home has introduced a quality assurance programme that measures its’ success in meeting the aims, objectives and Statement of Purpose of the home. Systems are in place to ensure residents’ financial interests are safeguarded. Management systems are in place, which are designed to safeguard the residents. The safekeeping of personal information about residents should be reviewed. Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 Page 22 EVIDENCE: The Manager has managed Royal Court for over 10years, is registered with the Commission for Social Care Inspection (CSCI) and holds the Registered Managers Award (RMA). She is well supported by a Deputy Manager, activities/training co-ordinator and other staff. Staff stated they were well supported by the management team. The home has undertaken an audit of the service provided at the home by undertaking staff and service user surveys. These have fed into a action and improvement planning framework written by the Manager for the home. This will be combined with a review of the service undertaken by a wider Bromford management team. The questionnaires returned by residents indicated the need to review menus that were acted upon through discussions with residents and a meeting held with the cook. The monies held securely by the home for three residents were inspected. Receipts of any purchases are kept and a record maintained of outgoing and incoming monies. Second witness signatures were present where staff on behalf of the resident had made purchases and in one case the resident’s own signature, where they had made a withdrawal of money from their ‘in house’ account. One resident has a relative who is ‘Power of Attorney’. Records kept at the home were generally of a good standard and up to date. The personal care plan files were stored in a locked filing cabinet where the key was stored on top of the cabinet in an unlocked room. There was evidence that health and safety issues are addressed in this home, with written policies, procedures and risk assessments, provision of necessary equipment and staff training. All necessary maintenance of equipment is undertaken in a timely fashion. This included the servicing of a bath hoist and the two lifts. Fire safety equipment and systems are regularly tested and serviced. Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 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 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 3 Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 Page 24 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. 2. Standard OP19 OP29 Regulation 23(2)(p) 12(1)(a) 19 Requirement Ground floor bedrooms must be provided with suitable ventilation. All staff working at the home must have PoVAFirst and CRB checks before they commence work. Timescale for action 30/04/07 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP12 OP37 Good Practice Recommendations Care plans should be regularly reviewed with the involvement of residents and a record kept of such a review. Further provision of transport, particularly for wheelchair users, should be provided to enable residents to pursue their interests and leisure pursuits. Care plans should be stored in a secure manner. Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Royal Court DS0000016568.V292319.R01.S.doc Version 5.1 Page 26 - 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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