CARE HOMES FOR OLDER PEOPLE
The Limes High Street Henlow Bedfordshire SG16 6AB Lead Inspector
Mrs Louise Trainor Unannounced Inspection 10:00 29 October 2008
th 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 DS0000014929.V372836.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 DS0000014929.V372836.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Limes Address High Street Henlow Bedfordshire SG16 6AB 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) 01462 811028 01462 811028 info@limescarehome.co.uk The Limes Care Home Ltd Mrs Joan Wilkinson Care Home 23 Category(ies) of Dementia (23), Mental disorder, excluding registration, with number learning disability or dementia (23), Old age, of places not falling within any other category (23) The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The maximum number of service users must not exceed 23. The home shall accommodate persons of either sex. No one falling into the category of MD (age range over 65 years) may be admitted into the home where there are already 3 persons of category MD (age range - over the age of 65 years) accommodated within the home. No person aged under 45 years of age who falls within the category of DE may be admitted to the home. 9th June 2008 4. Date of last inspection Brief Description of the Service: The Limes is a privately owned residential care home, providing care for 23 residents who have physical and mental health needs. The property is situated within the village of Henlow on the High street. It was built in 1840 and has been sympathetically converted by the proprietors to retain much of its original character and charm. In 2001 a further large extension was added to increase the registered accommodation to its present occupancy. Bedrooms located on the upper floor of the original house are accessed via staircases and a chair lift; bedrooms in the extension are accessible via a shaft lift. There is a large well-maintained enclosed rear garden and car parking is available at the front of the home. The fees for this home vary from £550.00 per week, to £850.00 per week, depending on the funding source. The Limes DS0000014929.V372836.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 1 star. This means the people who use this service experience adequate quality outcomes.
This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of service users’ views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit. This was the second Key Inspection for this year for this service. Since the first Key Inspection in June 2008, three Random Inspections have taken place on the 01/07/08, 12/08/08 and the 02/09/08. These included a specialist Pharmacist Inspection and compliance visits. Regulatory Inspector Mrs Louise Trainor carried out this inspection on the 29th of October 2008 between the hours of 10:10 and 13:45 hours. The home Manager was on leave on the day of the inspection, however the deputy manager was present throughout the visit to assist with any required information. Verbal feedback was given periodically throughout the inspection and at the end of the visit. Vast improvements have been identified, and there was commitment and enthusiasm from staff that was demonstrated throughout this report, we are now confident that this will continue. During this inspection we only tracked the care of one person. They had been recently admitted to the home. This involved reading their records and comparing what was documented, to the care that was being provided. Documentation relating to: staff training and supervision and medication administration, complaints, quality assurance and health and safety in the home were also examined. We also spent some time in the communal areas of the home, talking to staff and residents and observing the care practices that were carried out during this five and a half hour inspection hour inspection. We would like to thank everyone involved for their support and assistance during this visit to the home. The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection?
Medication administration processes had been identified as a problem at the last Key Inspection, and we had requested a visit from the Pharmacist Inspector. This had been followed up and compliance achieved. The menus had all been reviewed since our last visit, and are on display in the dining areas. There is also a colourful picture sign displayed in the dining room, offering a cooked breakfast each morning if residents wish. At the last Key Inspection we had commented that the place mats on the dining tables all had Christmas decorations on them. We felt this to be rather confusing for some people, particularly those with dementia, as although they were bright and cheerful it was only July. This time the placemats were bright, cheerful and appropriate with big flowers on them. The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 7 When we visited in August, there was decorating in progress. This was now completed, with areas such as stairways and corridors painted or repapered leaving it looking clean and bright. Two bedrooms had been redecorated and one had new flooring laid. There is an ongoing decorating / maintenance programme in place. Since we last visited on the 12/08/08 an abundance of training has either taken place or been introduced in this home. This includes; further medication training, brain injury training, Care planning, Safeguarding including Deprivation of Liberty, Moving and Handling, chiropody, fourteen staff have enrolled on long distance ‘Positive Dementia’ training and twelve have enrolled on a Mental Health diploma course. The staff that we spoke to were very positive and enthusiastic about all the recent improvements in the home, and stated that they felt more ‘valued and empowered,’ as they were being involved in making the changes. The manager of this home is also the owner, and although she was not present during this Key Inspection, both she and her deputy have able to demonstrate how hard they had worked at improving their knowledge and the standards of care in this home since our last Key Inspection in June this year. Both have a very positive outlook on the future of the home. Accidents and incidents are being recorded and reported appropriately, and where necessary safeguarding referrals are being submitted. What they could do better:
Medication Administration Record (MAR) sheets that we looked at were in order. However when code ‘0’ is used it is not always being defined, and the reverse of the MAR sheets are not always being used by all staff. There were pre admission assessments in place in each file, however these documents were not always dated and signed, so it was sometimes difficult to ascertain if these had been carried out in advance of the admission. Despite the improvements in documentation, there are still some details being omitted, such as dates and signatures, which we would expect to be identified through the homes internal audit processes. At present the home do not involve other professionals in their quality assurance process, this is work in progress, as is the annual summary report. The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 8 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 DS0000014929.V372836.R01.S.doc Version 5.2 Page 9 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 DS0000014929.V372836.R01.S.doc Version 5.2 Page 10 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, 2, 3, 4, 5 People who use this service experience good quality outcomes in this area. The home understands the importance of having enough information when choosing a care home. Pre Admission documentation was in place, however these documents are not always signed and dated. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: There is a combined Service User Guide and a Statement of Purpose in place for this home. This document is held electronically and reviewed at regular intervals, then issued to people as they enquire about the home. The document we were shown had been reviewed within the last year, and correctly reflects the details of the present manager and contact details for The Commission for Social Care Inspection (CSCI).
The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 11 We viewed the files of two residents in the home. There were pre admission assessments in place in each file, however these documents were not always dated and signed, so it was sometimes difficult to ascertain if these had been carried out in advance of the admission. For one resident in particular who had been attending the home on a daily basis, it was difficult to see where the day care ended, and when the residential care commenced. Generally these documents contained sufficient details relating to individuals’ needs, and were then used to generate initial care plans following admission. This home does not provide intermediate care. The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 12 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 People who use this service experience adequate quality outcomes in this area. People receiving care in this home are generally happy with the way staff deliver care and respect their dignity, however due to the omission of some information being documented in some care plans, there may be an inconsistency in the delivery of care. Medication records are generally in order, contain the required entries and are signed appropriately by staff. Internal auditing could be improved. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: We had previously had some serious concerns relating to this outcome area. However at the Random Inspection on the 12/08/08 we decided to repeat the tracking process of a resident, which we had previously tracked in June 2008. By doing this we could clearly see that the staff had updated and expanded
The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 13 care plans to cover all the areas of care we expected to see. For example a person who had a catheter in-situ now had a care plan that detailed how this was to be cared for. We also noted that he had fluid balance charts and turn charts. The fluid balance charts would benefit from being added up every 24 hours and the turn charts needed to indicate which side the person was put on, not just that they had been turned. Other details such as someone’s allergy to latex, also needs to be included in their care plans, to ensure staff always take precautionary measures of wearing vinyl gloves when delivering care to them. We also spoke to the district nurse who was visiting the home, she was satisfied that staff used her appropriately and sought her advice if necessary. It was also apparent from an overheard telephone conversation, that the staff had a good relationship with the local GP surgery and called out the GP appropriately. We also examined the personal file of a resident that we had previously identified as having frequent falls. It was clearly documented in her care notes, and contact had been made with the ‘Parkinsons Disease Consultant’ to monitor and manage this problem. Medication administration processes had been identified as a problem at the last Key Inspection, and we had requested a visit from the Pharmacist Inspector. This had been followed up and compliance achieved as follows on the 03/09/08. Examination of medication in use and associated medication administration records for all residents showed that there has been significant improvement in the quality and accuracy of records. The requirement that complete and accurate records are kept of all medication administered, or not, together with a reason why the medicine was not given has therefore been met, but it is important to ensure that hand-written records clearly identify the month and year of use (2 residents) and that the codes used, when medication is not given to residents (3), are clearly defined. Requirement by 31/07/08 to ensure residents are protected by being given medication only in accordance with the prescriber’s instructions. With exception of one confusing instruction relating to one resident, which was resolved during the inspection, no other examples were seem of where medication was not administered correctly. This requirement has therefore been met. A further requirement was made that medicines, including controlled drugs, must be stored properly, securely, and in appropriate environmental conditions. Inspection of medication storage facilities show that a new cupboard has been installed for the storage of controlled drugs and that this complies with the requirements of the relevant legislation. The temperature of the medicines storage room is now monitored and recorded daily and is acceptable. The temperature of the dining area where the medication trolley is
The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 14 located is not monitored or recorded to ensure the environment is suitable for the storage of medicines. Although the requirement has not been fully met, we expect the home to manage this rather than repeat the requirement. We followed up on this issue during this Key Inspection, and records were seen to indicate that temperatures are be closely monitored and recorded. A requirement was also made that staff authorised to administer medicines must be trained and assessed as competent to do so. The majority of staff are nearing completion of a distance learning course (last module due 5/9/08) and evidence was seen of enrolment on a local college course due to start in October 2008. The timescale for this requirement was set for 30/08/08 and has not been achieved. However, given the progress made towards completion of training and assessments of competence we expect the home to manage this rather than repeat the requirement. During this inspection we only briefly addressed medications and the Medication Administration Record (MAR) sheets that we looked at were in order. However when code ‘0’ is used it is not always being defined, and the reverse of the MAR sheets are not being used by all staff. The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 15 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 People who use this service experience good quality outcomes in this area. Residents in this home are involved in meaningful daily activities and have the opportunity to join in local community events. People are encouraged to make personal choices about their daily lives. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Since the last Key Inspection on the 09/06/08, we have made two visits to the home to carryout compliance Random Inspections. At the most recent Random Inspection on the 12/08/08 we found there were major improvements in this outcome area. These improvements had been sustained when we carried out this Key Inspection. The menus had all been reviewed since our last visit, and are on display in the dining areas. There is also a colourful picture sign displayed in the dining room, offering a cooked breakfast each morning if residents wish.
The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 16 At lunchtime on the day of this inspection, there was a choice of shepherds pie or cheese and onion pasty, both served with potatoes and vegetables, often grown and prepared by one of the residents, with a hot apple sponge for dessert. The menu for each week was on display, and indicated that a choice of nutritious meals was offered each day. There was a sign in the dining rooms reminding people that they only had to ask if they fancied something different and the cook would be pleased to serve it. At the last Key Inspection we had commented that the place mats on the dining tables all had Christmas decorations on them. We felt this to be rather confusing for some people, particularly those with dementia, as although they were bright and cheerful it was only July. This time the placemats were bright, cheerful and appropriate with big flowers on them. This home is in the process of recruiting a full time activity organiser. However at present all the staff are involved in the delivery of activities. An activity calendar is displayed in the entrance hall. There was an activity planned for most days, and for some days more than one. For example one morning some residents went for a coffee and shopping to Letchworth, in the afternoon others went for a coffee and shopping to Biggleswade, while those that remained at the home were entertained with board games and bingo. Other activities included massage, cooking, fishing and pub lunches and cinema trips to name but a few. Throughout the home there were collages, photographs and photograph albums of the recent activities and outings, such as a recent 70th birthday celebration at one of the village pubs, and a fishing trip boasting their ‘catches’. The home has downloaded these photographs electronically so that the resident’s families, who live a distance away, can request a disc and see what their loved ones have been doing in their leisure time. The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 17 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 People who use this service experience good quality outcomes in this area. The complaints procedure is supplied to everyone living in the home. Staff working at the home understand the procedures for safeguarding, and know when incidents need to be reported externally. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: This home has a complaints policy, which is easily accessible to residents and visitors to the home. It details expected timescales for responses, and guidance for any complainant that remains dissatisfied with investigatory outcomes. We viewed the complaints and compliment files. The home had not received any complaints since the previous inspection. There were however numerous cards of thanks. Safeguarding issues were also clearly recorded, and reported appropriately. There had been one referral made since our last visit, and we were already aware of. This was managed appropriately.
The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 18 Documentation indicates that the manager liaises with the safeguarding team as and when necessary, and they are also embracing the Mental Capacity Act including the Deprivation of Liberty, liaising with the local expert in this field. The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 19 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, 20, 21, 22, 23, 24, 25, 26 People who use this service experience good quality outcomes in this area. This home provides a clean, comfortable and homely environment for the people who live here. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The home was clean and tidy throughout, with the smell of dinner cooking giving a warm and homely atmosphere. When we visited in August, there was decorating in progress. This was now completed, with areas such as stairways and corridors painted or repapered leaving it looking clean and bright. Two bedrooms had been redecorated and one had new flooring laid. There is an ongoing decorating / maintenance programme in place.
The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 20 Bedroom doors now have nameplates on them, and pictures that are reflective of individual’s pasts, such as farming, are displayed to aid residents with dementia to locate their rooms. Residents have signed a consent form to indicate that they are happy to have their names on the doors. The gardens as usual were well tendered and tidy, and the home are planning a fireworks display with a ‘sausage sizzle’ and mulled wine, this coming weekend, where families and friends are invited to join the celebrations. The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People who use this service experience good quality outcomes in this area. This service recognizes the importance of training and delivers a programme that meets the National Minimum Standards. Recruitment procedures are fully adhered to so that residents are protected. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Since our last Key Inspection on the 9th of June, three new care staff had been appointed, although only one had commenced work, as Criminal Records Bureau (CRB) checks are outstanding for the other two. We checked the file of the carer that has commenced work, and all appropriate documentation had been obtained for them prior to their employment date. The manager has also ensured that Moving and Handling training, Health and Safety, Care Planning and Safeguarding training, is being delivered to new staff either prior to starting work or during their induction period. We acknowledged that there is a shortage of staff, and agreed for one of the new recruits to commence work in a supervised capacity as she had two appropriate references and a clear POVA first check. The only recruitment document outstanding was the CRB check.
The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 22 Each member of staff has a new file that contains training, supervision and appraisal documents. We looked at two of these files, and both indicated that the staff had received training in; care planning, environmental safety, safeguarding and medication, in the last few weeks. Staff have done both in house training in medication practices, and a distance learning medication course. Staff are also all being enrolled in distance learning courses in Mental Health and Dementia Care. These course are provided by Stonebridge College and when completed will result in staff receiving a diploma level certificate. Since we last visited on the 12/08/08 an abundance of training has either taken place or been introduced in this home. This includes; further medication training, brain injury training, Care planning, Safeguarding including Deprivation of Liberty, Moving and Handling, chiropody, fourteen staff have enrolled on long distance ‘Positive Dementia’ training and twelve have enrolled on a Mental Health diploma course. The staff that we spoke to were very positive and enthusiastic about all the recent improvements in the home, and stated that they felt more ‘valued and empowered,’ as they were being involved in making the changes. Evidence that appraisals and supervision is taking place, was present in the files that we looked at. If this continues, Minimum Standards will be achieved. The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 23 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, 32, 33, 36, 37, 38 People who use this service experience adequate quality outcomes in this area. The manager is aware of the importance of record keeping in the home. However omissions in documentation, indicates that auditing process may require improving. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The manager of this home is also the owner, and although she was not present during this Key Inspection, both she and her deputy have able to demonstrate how hard they had worked at improving their knowledge and the standards of
The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 24 care in this home since our last Key Inspection in June this year. Both have a very positive outlook on the future of the home, and the deputy told us that she now goes onto the CSCI website daily to update herself on any changes made to the guidance for procedures. We looked at health and safety documentation, including the fire log and maintenance records. There was evidence to indicate that fire call points and the emergency lighting were being tested on a regular basis and water temperatures tested and recorded monthly. Maintenance issues are being addressed in a timely fashion. Supervision records were examined, and indicated that staff are receiving regular 1:1 sessions with their line manager. Accidents and incidents are being recorded and reported appropriately, and where necessary safeguarding referrals are being submitted. The management in this home monitors the quality assurance, by using questionnaires that are given to the residents and their representatives to complete. At present the home do not involve other professionals in their quality assurance process, this is work in progress, as is the annual summary report. However with the vast improvements identified in so many outcome areas of this home since the last Key Inspection, we appreciate that they have prioritised issues for address, and other work is in progress although not yet complete. We will therefore extend the requirement relating to quality assurance, which is partially met. Despite the improvements in documentation, there are still some details being omitted, such as dates and signatures, which we would expect to be identified through the homes internal audit processes. Although the home does hold personal funds for five residents in this home, we did not inspect these records during this inspection, as at the previous inspection they were accurate, as were the invoicing procedures. The Limes DS0000014929.V372836.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 3 2 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X 2 2 3 The Limes DS0000014929.V372836.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. 1. Standard OP33 Regulation 24(2) Requirement A report reviewing the quality of care in this home for 2008 must be submitted to CSCI to ensure that the people who use this service are being listened too, and their opinions considered. Timescale for action 30/11/08 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 OP37 Good Practice Recommendations The home should consider how they can improve the auditing of records. The Limes DS0000014929.V372836.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 DS0000014929.V372836.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
