Inspection on 23/01/08 for The Limes

This inspection was carried out on 23rd January 2008.

CSCI found this care home to be providing an Good service.

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

The Limes 16/11/09

The Limes 25/11/08

The Limes 22/08/07

The Limes 01/08/06

The Limes 15/11/05

The Limes 02/06/05

The Limes 21/10/04

The Limes 02/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Limes 41/45 Church Street Bridgwater Somerset TA6 5AT Lead Inspector Kathy McCluskey Unannounced Inspection 23rd January 2008 13:00h 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 The Limes DS0000015987.V356751.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. The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Limes Address 41/45 Church Street Bridgwater Somerset TA6 5AT 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) 01278 422535 angelbre2003@yahoo.co.uk MR BRIAN THOMAS MRS ANGELA MARGARET BREWER Care Home 28 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (23) of places The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Registered for 23 persons in category OP and 5 persons in category DE(E) An additional bathroom equipped with assisted bathing facilities will be installed within 10 months from Date of Registration The large pond in the rear garden is protected in a manner which prevent accidents to vulnerable service users, within 8 weeks of Date of Registration Date of last inspection Brief Description of the Service: The Limes is located in a quiet but central part of Bridgwater. It is currently registered with the Commission for Social Care Inspection to provide personal care to up to 28 people over the age of 65, this includes 5 people who have a dementia. Service user accommodation is arranged on 4 floors, with lift access to all floors. All communal areas are on the lower floors. The registered provider is Mr Brian Thomas and the registered manager is Mrs Angela Brewer. The home is furnished in a comfortable domestic style. There are twenty-four single bedrooms and two double rooms. Twenty-three of the bedrooms have en suite facilities. The homes fees range from £373.00 to £420.00 and does not include hairdressing, chiropody and hospital transport. The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service for each outcome group under four general headings. These are; - excellent, good, adequate and poor. The home’s last key inspection was conducted by a CSCI Regulation Inspector and Pharmacist inspector on 22nd August 2007 & 11th September 2007. Following this inspection, a further visit was made to the home to follow up on immediate requirements raised at the key inspection. The providers and registered manager attended a meeting at the Commission’s office in Taunton to discuss their improvement plan. This Key unannounced inspection was conducted over one day (5hrs) by CSCI regulation inspector Kathy McCluskey. The registered manager and provider were available throughout this inspection and for feedback at the end at the inspection. At the time of this inspection 20 service users were living at the home. The registered manager advised that currently 2 service users were receiving care by means of their dementia. The inspection the inspector was able to spend time talking to service users and observing staff interactions. One visitor was available to talk to the inspector during the inspection. Comments received were very positive. All communal areas and a selection of bedrooms were viewed during this inspection. Records relating to staff, service users and health and safety were examined. The inspector would like to thank service users, staff and management for their time and cooperation with the inspection process. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The registered manager has taken action to address the 14 requirements raised at the last inspection. The home has received additional support and input from the Somerset Partnership mental health team to ensure that the needs of service users with dementia are appropriately and effectively met. Care planning systems have improved and now provide detailed information on the assessed needs of service users. Appropriate care plans are now in place to ensure that the psychological/mental health needs of service users are met. Positive improvements have been made in the provision of activities and social stimulation, especially with regard to meeting the needs of service users with dementia. Appropriate action has been taken to ensure that the home’s procedures for staff recruitment do not put service users at risk. The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 7 An additional visit was made to the home to follow up on an immediate requirement raised at the last inspection relating to the safe storage of hazardous substances and also unrestricted windows and wardrobes. No concerns were raised at the additional visit or at this inspection. Action has been taken to ensure that the home is tidy and free from trip hazards. Appropriate staff hand washing facilities and foot operated bins are now available in bedrooms where people require staff assistance to meet personal care needs. 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. The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 8 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 The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 9 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): 1, 3, 4 & 5 Standard 6 is not applicable as the home is not registered to provide intermediate care. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Prospective service users are provided with information about the home which helps to enable them to make an informed decision about living there. The home takes appropriate steps to ensure that prospective service users are fully assessed before a placement is offered. The home’s pre-admission procedures have improved. EVIDENCE: A Statement of Purpose and Service User Guide is made available to service users, prospective service users and their representatives. The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 10 The Commission have not been advised of any changes to these documents since the last inspection. The inspector was able to see evidence that service users had been appropriately assessed by the home prior to a placement being offered. As required at the last inspection, the registered manager had taken appropriate action to ensure that the home’s pre-assessment documentation contained sufficient information regarding the individual’s assessed needs. Assessments had also been obtained from other healthcare professionals. Evidence of the above was seen in care plans relating to two service users who had recently moved to the home. Prospective service users and/or their representatives are encouraged to visit the home prior to making a decision to move there. Two recent service users were positive regarding the admission process. The inspector was informed that the home currently has two service users in the category of dementia (the home is registered to accommodate a maximum of five service users in this category). At the time of this inspection, the home appeared to be meeting the needs of these service users. At previous inspections concerns had been raised by the Commission regarding the home’s ability to fully meet the needs of service users with dementia given the layout of the home and the lack of specialist training for staff. Since the last inspection, the registered manager has researched dementia care through reading and visiting other dementia care homes and some training has been arranged for staff. The mental health team from the Somerset Partnership have also been providing additional input and support following concerns raised at the last inspection. The registered manager needs to ensure that careful consideration is given for future referrals in this category to ensure that individual’s specialist mental health needs can bee fully met by the home. The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 11 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. The home’s care planning procedures have improved. The home’s procedures for the management and administration of service users medication have improved since the last inspection. Service users are treated with respect and their privacy is respected. EVIDENCE: Care records relating to three service users were examined in detail at this inspection. It was positive to note that the registered manager had been proactive in addressing requirements raised at previous inspections regarding service user care plans. The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 12 Care plans contained clear information regarding an individual’s assessed needs and also took into account the preferences of the individual. Clear instructions were in place for staff detailing how the individuals assessed needs should be met. The home has received additional support and input from the Somerset Partnership mental health team regarding the care of service users at the home who have dementia. The inspector was able to see that care plans were now in place to meet service users psychological/mental health needs. There was evidence that care plans had been reviewed at least monthly and the inspector was able to see that care plans had been updated to reflect changes in assessed needs. There was no evidence in care plans examined that service users or their representatives had been involved in the care planning process. The registered manager stated that she always consulted with service users about their plan of care and ascertained their wishes and preferences. Evidence was forwarded to the Commission to support this. It has been recommended that documented evidence is maintained within the service user care plan in future. Up to date assessments were seen relating to risk, moving and handling and nutrition. Records indicated that service users have appropriate access to healthcare professionals. The registered manager confirmed that the home received very good support from healthcare professionals. Service users are weighed monthly and there was evidence in one care plan examined that appropriate action had been taken where weight loss had been identified. Service users spoken with indicated that they were satisfied with the care they received and that the home looked after them very well. The home’s procedures for the management and administration of service users medication were examined and improvements were noted. Medication Administration Records (MAR) had been appropriately completed and there were no gaps in signing for prescribed medicines. A policy was in place relating to the administration of homely remedies. Medicines were found to be securely stored and there did not appear to be excess stock levels. The majority of creams in used had been labelled with an open date. It has been recommended that the home also identifies the use by/expiry date. The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 13 Service users spoken with stated that they were treated with respect and that ‘staff are very kind and they will do anything for you’. Staff were observed interacting with service users in a warm and professional manner. The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 14 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 Good. This judgement has been made using available evidence including a visit to this service. People with dementia are benefiting from improvements in social stimulation and activities. Visitors are made welcome at the home. Service users are offered a wholesome and varied menu. EVIDENCE: Since the last inspection the home have made improvements in the provision of activities available for service users with dementia. During this inspection, service users seated in the lounge in the lower ground floor were enjoying various activities and were supported by two care staff. All service users were observed to be engaged in an activity they enjoyed. The home has created a selection of ‘rummage’, ‘sensory’ and ‘smell’ boxes especially for service users with dementia. The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 15 Staff confirmed that they now spend quality time with service users during every morning and afternoon and that service users benefited and enjoyed this time. Individual records are maintained for activities and these confirmed that all service users were offered a regular programme of appropriate and interesting activities. During the afternoon of the inspection, outside entertainers were at the home providing a range of cultural dance and music. Service users appeared to enjoy this very much. The registered manager has booked two training sessions for staff relating to providing activities for people with dementia. These are due to take place at the end of January and end of February. These improvements have a very positive outcome for service users. The inspector met with one visitor during this inspection who was very positive about the home and the care that their friend received. The visitor confirmed that they were always made to feel welcome and that staff were always available. The home welcomes visitors at any reasonable time in accordance with the preferences of the service user. Service users can choose where to see their visitors. A range of communal areas are available or the service user can see their visitors in the privacy of their own bedrooms if they choose. Service users spoken with during this inspection confirmed that they could choose how and where to spend their day. ‘You can go to bed when you like’ ‘I can’t fault it, they are marvellous’. Service users were very positive about the meals at the home. ‘The food is lovely’, ‘Always plenty to eat and drink’, ‘The cook is marvellous’. All meals are freshly prepared at the home by the cook. The main meal is enjoyed at lunch time and the inspector observed a staff member asking service users for their preferences for tea and the following lunch time. The menu appeared wholesome and varied. It was positive to note that some staff had recently developed a book containing pictures of meals and this is used to assist people with dementia to make choices. The dining area is located on the lower ground floor. Tables were noted to be attractively laid with condiments, napkins and drinks available. Seating appeared comfortable. Service users were seen to access this area via the home’s passenger lift. The lift has limited space but no concerns were noted. The Limes DS0000015987.V356751.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. The home’s procedures for investigating complaints have improved. Improvements in staff training and staff recruitment procedures now offer better protection for service users. EVIDENCE: The home has a complaints procedure which, as recommended at the last inspection is displayed in the reception area of the home. The home has received one complaint since the last inspection and there was evidence that this had been investigated and resolved within an agreed timescale. This was a requirement at the last inspection. Service users spoken with stated that they would not hesitate in raising concerns with the registered manager or staff if they had any. No concerns were raised with the inspector during this inspection. As required at the last inspection , the registered manager has taken appropriate action to ensure that all staff have received training in abuse. A copy of Somersets revised policy (May 2007) on Safeguarding Adults was available at the home. The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 17 The home’s procedures for staff recruitment have improved and now offer better protection for service users (refer to standard 29). The Limes DS0000015987.V356751.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, 21 & 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Limes provides a homely, clean environment for service users. The home have taken steps to ensure that the home remains tidy and free from trip hazards. The home’s procedures for infection control have improved. EVIDENCE: Since the last inspection, a number of bedrooms have benefited from new furniture which includes lockable space. New carpets are planned for some areas. During this inspection six bedrooms and all communal areas were seen. All areas were comfortably furnished, warm and clean. The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 19 As required at the last inspection, action had been taken to ensure that areas were free from trip hazards. At this inspection, communal areas appeared tidy, homely and comfortable. The registered person had taken action to address the requirements raised at the last inspection relating to missing tiles and broken unit in the kitchen, securing an identified carpet and securing identified wardrobes and windows. Risk assessments are in place for those radiators not guarded. A call bell system is installed throughout the home. As required at the last inspection action had been taken to address two call bells requiring attention. Records are maintained indicating that regular checks are made on the call bell systems. To reduce the risk of the spread of infection, liquid soap, paper towels and foot operated bins are available in bedrooms for service users who require staff support to meet their personal care needs. Personal toiletries are stored in service user’s bedrooms. No communal toiletries were seen to be in use as noted at the last inspection. The Limes DS0000015987.V356751.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, 29 & 30 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a stable staff team. Staffing levels appear appropriate to the needs of service users currently living at the home. Staff recruitment procedures have improved and now offer better protection for service users. EVIDENCE: The registered manager confirmed that the home has a stable staff team and has not had to use agency staff. At the time of this inspection 20 people were living at the home. The registered manager advised that current staffing levels were sufficient to meet the needs of people living at the home. The inspector was informed that the home is currently staffed as follows; 0800-1400hrs – 4 care staff 1400-1800hrs – 3 care staff The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 21 1800 – 2200hrs – 3 care staff Night – 2 waking care staff In addition to the above, the registered manager is on duty 0830-1730hrs weekdays. An additional senior carer provides cover throughout the week. Kitchen and domestic staff are also employed and the registered provider is available for maintenance work. As recommended at the last inspection, the registered manager has reviewed the deployment of staff to ensure that service users using the lounge on the lower ground floor are appropriately supervised. This was observed during the inspection and confirmed by staff. Neither service users, staff or the visitor met with expressed any concerns about staff levels at the home. The inspector examined the recruitment file for the member of staff recruited since the last inspection and was able to see evidence that requirements raised at the last inspection had been addressed. All required documentation was in place which included an enhanced criminal record check (CRB) and protection of vulnerable adults check (POVA). Staff application forms have been reviewed to prompt any gaps in employment to be explored. Newly appointed staff now undertake an induction programme following the recommendations of the Skills for Care Common Induction Standards. Evidence of this was seen in the staff file examined. This was recommended at the last inspection. The Limes DS0000015987.V356751.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 home is effectively managed. Systems are in place which seek the views of service users. The home’s procedures relating to health & safety have improved. EVIDENCE: Angela Brewer has been the registered manager for 6 years and has worked at the home for the past 19 years. The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 23 Through discussion with the registered manager, staff and service users it is apparent that she has a good knowledge and understanding of the needs and preferences of service users at the home. Angela liaises closely with other relevant professionals and it should be pointed out that she was proactive in addressing the concerns raised at the last inspection. Angela confirmed that she researched the care of people with dementia by utilising the internet and visiting other registered homes both locally and in Bristol. Service users were positive about the registered manager and stated that they found her very approachable. Regular meetings are held for service users and staff. Minutes of the latest meetings were seen and it was apparent that service users and staff were encouraged to express their views. Questionnaires are sent out to service users and their representatives to seek their views on the quality of the service provided by the home. The registered manager confirmed that these were due to be sent out this year. Progress will be followed up at the next inspection. The home currently manages small amounts of monies on behalf of two service users. The registered manager confirmed that the home does not act as appointee for service users. The records and monies relating to these service users were examined at this inspection and no concerns were noted. Transactions had been confirmed with two signatures and receipts were available. Regular audits are carried out by the provider. Monies were seen to be securely stored. The home’s procedures relating to Health & Safety were examined and the findings were as follows; FIRE SAFETY – As required at the last inspection, a fire risk assessment was completed and forwarded to the Commission. Appropriate in-house checks are being carried out on the home’s fire alarm systems. It has been recommended that records relating to checks on the emergency lighting systems include the zone/areas checked. Fire fighting equipment was last serviced by an external company on 21/08/07. GAS SAFETY – The home has an up to date annual Landlords Gas Safety Certificate. ELECTRICAL SAFETY – Records indicated that annual testing on the home’s portable electrical appliances were carried out on 29/08/07. The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 24 EQUIPMENT SERVICING – The inspector was advised that the home has one bath hoist and a passenger lift. Six monthly servicing was last carried out in November and December 2007. HOT WATER OUTLETS – To reduce the risk of scalding, the home carries out regular checks to ensure that hot water outlets remain within safe limits. It has been recommended that bath and shower outlets are clearly identified on the form to ensure that they are all checked at least monthly. The safe upper limits stated by the Health & Safety Executive (HSE) are 44c for bath outlets and 42c for showers. To reduce the risk of injury to service users, wardrobes are secured to the wall and windows are fitted with restrictors. Immediate requirements issued at the last inspection were followed up with an additional visit to the home to check compliance. ACCIDENTS – The home maintains appropriate records relating to accidents. As recommended at the last inspection, the registered manager now completes monthly audits on accidents which enable any traits to be identified. An immediate requirement was issued at the last inspection following concerns regarding the safe storage of cleaning materials. No concerns were raised at a follow up inspection and no concerns were raised at this inspection. Dental tablets are securely stored to reduce the risk of accidental ingestion. The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 3 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x 3 x x x x 3 STAFFING Standard No Score 27 3 28 x 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 The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP9 Good Practice Recommendations Documented evidence of service user involvement should be maintained within the service user care plan. To ensure that prescribed creams/lotions are not administered after their ‘shelf life’, the registered manager should ensure that items are identified with the expiry date once opened. When conducting monthly checks on the home’s emergency lighting, it is recommended that the zone/area checked is recorded. The registered person should ensure that all bath and showers are clearly identified on the home’s temperature check form to ensure that these hot water outlets are checked monthly to ensure that temperatures do not exceed safe upper limits. 3. 4. OP38 OP38 The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 The Limes DS0000015987.V356751.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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