Inspection on 05/06/07 for The Old Vicarage, Chippenham

This inspection was carried out on 5th June 2007.

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

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

Other inspections for this house

The Old Vicarage, Chippenham 01/03/06

The Old Vicarage, Chippenham 03/10/05

The Old Vicarage, Chippenham 02/03/05

The Old Vicarage, Chippenham 14/07/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

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 Old Vicarage (The) St Mary`s Street Chippenham Wiltshire SN15 3JW Lead Inspector Susie Stratton Unannounced Inspection 9:55am 5 & 19th June 2007 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 DS0000059130.V334749.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. DS0000059130.V334749.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Vicarage (The) Address St Mary`s Street Chippenham Wiltshire SN15 3JW 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) 01249 653838 01249 651173 oldvicwilliams@hotmail.com The Old Vicarage (Chippenham) Ltd Miss Cheryl Williams Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places DS0000059130.V334749.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st March 2006 Brief Description of the Service: The Old Vicarage is a private care home for up to 20 older people. The home is owned and run by Mr and Mrs Williams and Cheryl Williams, who have formed a limited company. The Old Vicarage is a period property located opposite the Church and within walking distance of local shops and amenities. The accommodation is spacious and well decorated. Bedrooms are mostly large and furnished as bed sitting rooms, with en-suite areas. The communal areas include a large lounge and a formal style dining room. There is a large garden, leading down to the river, with patio areas. Cheryl Williams is the registered manager and works alongside a care manager and a team of permanent staff members. A key worker system is in operation, with each staff member providing personal care and carrying out cleaning tasks in the home. All staff also take turns at performing the cooking and laundry. A copy of the service users’ guide is kept in the entrance hall to the home and all residents are given a copy on admission. Fees range from £380 to £460 per week. DS0000059130.V334749.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included visits to the service and takes into account the views and experiences of people using the service. As part of the inspection, 20 questionnaires were sent out and 8 were returned. Comments made by residents and their relatives in questionnaires and during the inspection have been included when drawing up the report. The home also provided information requested by the CSCI prior to the inspection, relating to policies, residents and staff. The site visits took place over two days, on Tuesday 5th June 2007 between 9:55am and 4:00pm and Tuesday 19th June 2007 between 9:55am and 11:20am. The first site visit was unannounced. The registered manager, Cheryl Williams, was on duty for both site visits. During the site visits, the inspector met with thirteen residents and two relatives. The Inspector reviewed care provision and documentation in detail for four residents, one of whom had recently been admitted. As well as meeting with residents and visitors, the inspector met with two carers, the care manager and one of the owners of the home. The inspector toured all the building and observed a lunch-time meal. A medicines round was observed as well as systems for administration of medicines. A range of records were reviewed, including staff training records, staff employment records and policies and procedures. What the service does well: The Old Vicarage is a distinctive building, which is well maintained and has preserved many of its original features. Residents’ rooms are large and they are encouraged to bring in items of their own. The home is well positioned, close to the centre of the town and its amenities. Staff are supported in developing their skills through a range of training opportunities. There are safe systems for recruitment of staff and all staff are fully supported in their induction period. These systems ensure that residents are cared for by skilled staff, who can meet their needs. Residents and their relatives commented on the home. One person reported on the “warm and friendly welcome for everyone” another described the ethos of home as “cooperative & forward thinking” and another “the home is comfortable, non-institutional, busy, friendly and staffed by people who are invariably cheerful and helpful”. People also commented on the staff, one reported “I have a named carer and she’s excellent”, another “They’re DS0000059130.V334749.R01.S.doc Version 5.2 Page 6 agreeable and anxious to help you” and another “They all seem very professional and caring.” What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000059130.V334749.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000059130.V334749.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3. The home does not admit persons for intermediate care, so 6 is N/A Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service. Residents have full information about services offered prior to admission. To ensure that their diverse needs can be met, a full needs assessment is completed on every resident. EVIDENCE: All prospective residents are seen by the manager or her delegate before admission. Prior to making a decision to be admitted, residents are asked to visit the home and look at their room. As much as possible, assessments of need take place when they visit. Assessments are also obtained from other professionals, such as their social worker. Even if prospective residents are being admitted urgently, the manager reports that she always meets with the person before admission. Admission assessments seen were completed in detail and included a range of information relevant to the resident. The DS0000059130.V334749.R01.S.doc Version 5.2 Page 9 information obtained is then used as a base-line for development of the person’s care plan. All resident’s files included a contract, which they or their representative had dated and signed. The contract complied with current regulations and guidelines. The home has a statement of purpose and service users guide. A copy of the full service users’ guide is available in the front hall. Residents are also given their copy of the guide on admission to the home. In order to ensure that all residents are made aware of the contents of inspection reports they should be given a copy of the summary of the inspection report in their own service users’ guide, together with information on how to obtain a copy of the full inspection report. All of the ten persons who completed the questionnaire reported that they had had enough information about the home before they had decided on admission. One person reported that they knew about the home by word of mouth and another that they had known of it because of their involvement with the church. DS0000059130.V334749.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. Residents have individual plans of care, which document their health and personal care needs. These are drawn up by staff with the residents. Residents are supported in continuing to be responsible for their medication. Where the home do support them, there are full systems to do so, apart from one area, which needed attention. EVIDENCE: Residents have written plans drawn up by a designated member of the staff, to direct staff on how care needs are to be met. Residents are assessed for risk; for example, one resident had been assessed for risk of falls and a care plan had been drawn up to direct staff on how risk was to be reduced. Where a resident needed communication aids, this had been noted. Manual handling assessments had been completed. Residents are weighed regularly. There was evidence that action was taken if significant changes in weight were noted. Care plans were evaluated regularly and changed if indicated. Some records DS0000059130.V334749.R01.S.doc Version 5.2 Page 11 showed gaps between entries and at the end of entries. It was recommended that a line be drawn across such blank spaces, to prevent later additions. This had been addressed by the second site visit. Residents and their relatives reported that the home could meet their needs. They reported that they were regularly consulted about their care plans. One reported “The standard of care received is wholly satisfactory”, another; “I made a mess – the staff were so helpful” and another “All are helpful and effective”. The home reported that they had good working links with local healthcare professionals, including GPs and district nurses. One resident reported “Very good support with medical issues.” Records relating to one resident also provided evidence of effective relationships with local mental health services. It was noted as good practice that residents were able to have a kettle in their room or to continue having hot water bottles if they chose. As these can be seen as a risk for older persons, it is advisable that the home individually assesses risk to all residents who request such items and that these risks are regularly reviewed. This had been addressed by the second site visit and all relevant care plans up-dated. The home occasionally cares for very frail residents, with the support of district nurses. Where this is the case, they maintain monitoring records, to ensure that residents who are at risk of pressure damage are regularly moved and are offered regular fluids. On the first day of the site visit, records seen had not been completed in full by all staff. This must be done, as the home cannot otherwise provide evidence that they are meeting the needs of such frail persons. By the second day of the inspection, this had been addressed in full. All medication administered by home staff to residents were securely stored. There are records of medicines received into the home, given to residents and disposed of from the home. The care manager was aware of correct procedure for disposing of dropped tablets. On the first site visit, some residents were prescribed Controlled Drugs. These drugs were correctly stored; however a record was not maintained in a book as is required for such categories of drugs, as is directed on the CSCI’s web site for such drugs. By the second site visit, no residents were prescribed such drugs. On the first site visit, a few medicines records showed gaps, the care manager was aware of these gaps and was following the matter up with relevant carers. Residents are supported to self-medicate where possible. Where residents wish to administer their own medication, an individual risk assessment is drawn up, this is regularly reviewed. The home has a medications policy. This was up-dated during the inspection process, to reflect the actual good practice which was reported and observed. Residents’ privacy and dignity is respected. One relative reported “I have only seen staff deal with everyone with respect and care”. Staff consistently DS0000059130.V334749.R01.S.doc Version 5.2 Page 12 knocked and awaited a reply before going into a resident’s room. All care was given behind closed doors. Frailer persons looked comfortable, were dressed in their own clothing and had clean hair and nails. Residents reported that they could receive their visitors in private if they wished and this was also observed to take place during the inspection. DS0000059130.V334749.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. Residents are able to choose how they live their lives while in the home. This reflects their diverse needs and preferences. EVIDENCE: The home has an activities programme, which is displayed and residents can participate as they wish. One relative reported “Every resident feels included”. Some residents spent all their days in the communal rooms. Two residents were sitting out on the patio; they reported that now the better weather had come, they spent as much time out there as they could. Other residents reported that they preferred to remain in their rooms and that this was respected. Many residents reported that they maintained close contact with family and friends and so did not need entertaining as such. One person reported “I get lots of visitors” and another “My family take me out”. One relative reported “They give a nice homely family atmosphere. They take time to chat to visitors and let me know how [my relative] has been doing since the last visit.” DS0000059130.V334749.R01.S.doc Version 5.2 Page 14 The closeness of the home to the middle of Chippenham means that visitors can pop in when passing. The home has close links with the local church and services are held in the home for residents who wish to participate on a regular basis. Residents are able to choose how they spend their days. One person reported “It’s no problem – I can get up and go to bed when I want” another reported “I can stay up late if I want to”. One relative reported “This is not the life [my relative] would choose as [they] would like to be more active. However staff appear to do all they can to encourage [my relative] to take part in activities as well as looking after more basic needs”. Residents are able to bring items of their own into their rooms and many had done so. Most rooms were highly individual, reflecting the resident’s likes and preferences. As would be anticipated in any care home, there was a range of opinions about the meals, these varied through “Generally meals not to a high standard” through “The food is quite good on the whole” to “The food is very good”. Residents are offered a set menu, which is available to all residents in the dining room. Several residents in their questionnaires reported that they were not offered a choice. However records showed that residents could and often did request a meal other than that on the menu. In order to ensure that residents do know how to request a different meal, this information should be included in the home’s service users’ guide. The dining room is attractively laid out. Residents can eat in the dining room or their own room, as they prefer. DS0000059130.V334749.R01.S.doc Version 5.2 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. 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 visits to this service. Residents concerns are listened to and there are systems to protect them from abuse. EVIDENCE: The home has a complaints procedure, which is included in the service user’s guide. Of the seven people who responded to this section of the questionnaire, five reported they always, one usually and one sometimes knew who to talk to if they were not happy and that the person responded appropriately. One person reported “My socks went missing and in no time at all they found them.” One person reported that if they had concerns, they would go to the care manager reporting that they were “a listener and a doer”; another reported that they would speak to the owner and that he “sorts things out”. The home maintains a log of complaints. No complaints have been made to the CSCI since the last inspection. Staff spoken with were aware of systems for safeguarding adults. No referrals have been made via the local procedure since the last inspection. The home’s policy was amended during the inspection, to fully reflect the local procedure. The home does not use any restraints. DS0000059130.V334749.R01.S.doc Version 5.2 Page 16 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, 23 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. Residents of the home are given a pleasant, clean, well-maintained environment, although some attention was needed to a few specific areas, to ensure that residents are fully protected from risk of cross infection. EVIDENCE: The Old Vicarage is a listed building and is maintained with the ethos of such a building. Resident’s rooms are large and they are able to adapt them to suit their own needs and any possessions which they wish to bring in with them. One person described their room as “very nice”. All parts of the home inspected were clean and well maintained. Rooms are provided on different floors, with a lift in-between. There is a large dining room and sitting room, with a separate small television lounge. One resident reported about the communal rooms: “We’re very lucky being in these lovely rooms”. There is a DS0000059130.V334749.R01.S.doc Version 5.2 Page 17 terrace with steps down to a large sloped garden area. A ground floor entrance to the garden is available for people who cannot manage a flight of steps. Rooms on one side of the house look out over a quiet street and the church. On the other side, they look our over the river Avon. One resident described the view as “tremendous”. As well as en-suite facilities, there are also disabled communal bathrooms. The owner reported on planned improvements to be made to one of these areas, to make it more suited for disabled persons. During the first site visit, it was noted that tablets of soap had been left in two of the bathrooms. Communal use of soaps can present a risk to cross infection. These had been removed by the second site visit. The back and underside of the bath hoist in one of the assisted bathrooms was showing signs of green discolouration and limescale. This had been fully cleaned by the second site visit. None of the communal bathrooms had single use systems for hand cleansing and as staff reported that they do assist residents in bathrooms with their personal care, this is needed, to ensure that staff can properly cleanse their hands before and after assisting residents with their personal care and so preventing risk of cross infection. By the second site visit, there was evidence that appropriate equipment was on order for communal bathrooms. The home provides its own laundry service. Discussions with staff showed that they had clear systems for the management of potentially infected laundry. The laundry is in an older part of the home and an accumulation of dust was observed on the floor and cobwebs in the ceiling. Staff were advised that as micro-organisms can live where dust is visible, that all laundry areas need to be regularly vacuumed to remove any such material, to reduce risk of cross infection. By the second site visit, all dust had been removed and regular vacuuming of laundry areas included on the cleaning rota. DS0000059130.V334749.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence, including visits to this service. Residents are supported by staff who have been properly recruited and are fully trained in areas relating to resident care. EVIDENCE: The majority of staff have worked in the home for many years. A review of rosters and discussion with staff showed that staff are prepared to work flexibly, so temporary/agency staff are not used. The owners and manager of the home also work shifts when needed, for example to support the night carer where a frail resident needs additional support. Generally residents felt that staff were available to support them. One person reported “Staff are always on the lookout for if you need help” and another “If I ring my bell, they come straight away” but one person did report “Generally the staff are cooperative but at times they do work under pressure”. The home has a safe system for recruitment of staff. The files of the three most recently employed staff were reviewed. All showed that staff had police checks, had supplied proof of identity and provided information on previous work experience. Two references and a health status check are obtained for all staff. All staff are interviewed and work at least four shifts supernumerary when they commence employment. The period worked supernumerary varies DS0000059130.V334749.R01.S.doc Version 5.2 Page 19 according to each person’s previous experience and skills. All staff are mentored by an experienced member of staff when they commence working in the home. Staff are given a contract of employment, which they sign and a handbook, which includes their job description. All records were clear and consistently maintained. All staff commence a formal induction on commencement of employment. The induction programmes seen complied with current guidelines. On completion of their induction, staff are supported to commence NVQ training. Well over 50 of staff are trained to NVQ 2 or above. All staff receive training in mandatory areas such as manual handling, food handling and fire safety training. All staff who administer medicines are trained in management of medications. The manager has a matrix of training, so that she can ensure that all staff undertake training in mandatory areas. All staff folders also contain individual staff training profiles. These show the range of training opportunities offered and taken up by staff. One carer reported on the training that she had received in the past year; this included medication, manual handling and fire safety. She also reported that she was to undertake infection control training later in the year. The carer showed an understanding of supporting continence needs for residents. She reported that if, as a carer she was not sure about a certain matter, that senior staff were always happy to help you. For example she had not been sure about how to wash a certain resident’s eyes and she had been shown how to do this, so that she could do it properly and safely. DS0000059130.V334749.R01.S.doc Version 5.2 Page 20 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, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. Residents are supported by the management ethos of the home, which seeks to consult residents on services provided, to support staff in their roles and to ensure that principals of health and safety are adhered to. EVIDENCE: The manager of the home has been in post for some time and so has experience of managing the service. She has also gained an NVQ 4 in management and care. She reported that she regularly uses information systems, for example via the internet, to ensure that care provided is consistent with current good practice guidelines. She is also regularly attends external meetings such as the local infection control group. The manager DS0000059130.V334749.R01.S.doc Version 5.2 Page 21 showed an interest in developing and extending services to residents. This is evidenced by the prompt action she took to address matters identified during the first site visit. A review of the home’s file also showed that she consistently addressed requirements and recommendations identified during the inspection process. The home has recently introduced a system for quality audit and management. All accidents are regularly audited to identify any trends. Residents and their supporters are asked to comment on service provision by questionnaire, generally those seen were very positive. Responses to questionnaires are then analysed and used to improve service provision. Questionnaires are not completed anonymously. The manager reported that this did not seem to prevent residents putting down what they thought about the service. The manger also holds regular staff meetings at which minutes are taken. Staff are regularly supervised. All newly employed staff are appraised when they complete their induction. Supervision records were individually completed and a variety of approaches were used, including 1:1, group supervisions and direct observation. The home does not look after any money for residents. Staff will support residents by doing shopping for them. Two residents reported that staff would come round once a week to get a list of what they wanted, take money for this and then go and purchase items for them and give them back their change and receipts. This was supported by the home’s records. The home has systems for ensuring health and safety. As noted in standard 30 above, staff are regularly trained in areas relating to health and safety. The tour of the home indicated that staff are complying with principals of fire safety. As noted in standard 26 above, a few areas relating to infection control were identified; these were dealt with by the end of the inspection. The home has recently reviewed and further developed its health and safety policies. There is a full system for regularly checking health and safety; this is regularly completed and provides clear evidence of systems for ensuring health and safety across the home. The home owns a hoist, which is regularly serviced. The hoist cannot go into the lift, so it remains on the floor where it is needed. If residents are at risk of falls, they have clear care plans about how they are to be assisted from the floor if they do fall, so that staff are aware of their responsibilities, if this does happen. DS0000059130.V334749.R01.S.doc Version 5.2 Page 22 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 3 3 X 4 X x 2 STAFFING Standard No Score 27 3 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 DS0000059130.V334749.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 13(2) Requirement Where the home are administering Controlled Drugs, appropriate records must be maintained, in accordance with current legislation. Timescale for action 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The service users’ guide given to service users on admission should include a copy of the summary of the inspection, together with information on how a copy of the full report can be obtained. The service users’ guide should be amended to inform service users about choices offered by the home at meal times. 2. OP1 DS0000059130.V334749.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 DS0000059130.V334749.R01.S.doc Version 5.2 Page 25 - 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!