Inspection on 03/10/07 for Towneley House

This inspection was carried out on 3rd October 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

Towneley House 28/02/07

Towneley House 06/12/05

Towneley House 09/06/05

Towneley House 28/10/04

Towneley House 28/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Towneley House 143/145 Todmorden Road Burnley Lancashire BB11 3HA Lead Inspector Mr Graham Oldham Unannounced Inspection 09:30 3rd and 4 October 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 Towneley House DS0000009456.V346926.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. Towneley House DS0000009456.V346926.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Towneley House Address 143/145 Todmorden Road Burnley Lancashire BB11 3HA 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) 01282 424739 Mr Stephen Alfred Shillito Mrs Barbara Karen Shillito vacant post Care Home 22 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (10) of places Towneley House DS0000009456.V346926.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The service is registered to provide personal care for a maximum of 22 service users Staffing levels must be maintained at the levels stated in the home’s proposals, that is, 3 care staff will be on duty at all times between the hours of 7.30am and 10.00pm and 2 waking night staff between the hours of 10.00pm and 8.00am, giving a total 444.5 care hours. In addition there should be a manager on shift for a minimum of 105 hours per week, a minimum of 30 domestic hours and 40 cooking hours. The service is registered to provide care for 10 older people, not falling within any other category and 12 older people with dementia. 28th February 2007 4. Date of last inspection Brief Description of the Service: Towneley House is care home registered to provide personal care and accommodation for 12 elderly people and 10 elderly people with dementia. The home is of an older type building situated in close proximity to Burnley town centre and Towneley park. It comprises 3 floors, linked by a stair lift. Private accommodation consists of 11 single rooms, five of which were at least 10 sq ms, and 5 double rooms, two of which were under 16 sq ms. Nine single and four double rooms were en suite. Communal areas consisted of 2 lounges, a dining room and a smaller dining room/smoke room. Renovations and developments were underway to increase the amount of communal space, increase some bedroom sizes and the number of single rooms, and enhance the facilities. The registered person was managing the home. Training and assessment material from the Alzheimers Disease Society was in use to ensure staff can meet the needs of the residents with dementia. The home had a mini bus that enabled residents to enjoy a range of supported outings and activities to such places as the Trafford Centre, Bury market, the coast and country runs. Residents have had the opportunity of an annual holiday abroad in recent years. A statement of purpose and service users guide is available for residents or their families to be informed of the facilities and services the home provides. The fees for Towneley House ranged from £342 - £396 per week. Not included within the fees are hairdressing, personal toiletries and money for outings. Towneley House DS0000009456.V346926.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection, which included a visit to the home, took place on the 3rd & 4th of october 2007. Much of the information gained was obtained from talking to residents, a relative and staff members. People living within the home allowed the inspector to call them residents. Three residents were case tracked. Case tracking gave the inspector an overall view of the specific care for the individual resident by checking their plans of care, other documentation and talking to staff, residents and a family member about the care they gave each resident case tracked. Residents were then asked if the care they received was what they needed. One resident did not wish to participate. A visitor supplied information about the care and services available. Two staff members were questioned about the care of the residents case tracked and the training they had undertaken. Some of the views have been reported collectively with specific comments contained within the body of the report. The inspector took detailed notes during the inspection, which have been retained as evidence. Staff were directly and indirectly observed carrying out their tasks and interacting with residents. Paperwork examined included plans of care, assessment documentation, policies and procedures or documents relevant to each standard. A tour of the building was conducted on day two of the inspection. This inspection was conducted on two days due to staff and many residents going on a pre-arranged trip on day one. What the service does well: One relative sent a letter to the inspectorate dated 03/10/07, which said since my mother has lived at Towneley House her care has been of a very high standard. I would say her physical, mental and emotional health has improved. She has nutritious meals, excellent social environment and good medical care. The staff are friendly, caring and well trained. The atmosphere in the home is warm and welcoming. Most important of all, my mother has settled in well, made friends and feels safe. Management is well organised and communication good. I am more than happy with the care my mother receives. PF The relative was very satisfied with the care her mother received. Resident’s case tracked said, “Its all right in here – I am all right. I have been here a while” and “I have been here a long while. I have become pals with Towneley House DS0000009456.V346926.R01.S.doc Version 5.2 Page 6 another resident since I came here”. One visitor said, “She was in sheltered accommodation and had a few incidents such as wandering. She had carers but seemed depressed and was not eating. She set fire to carpet and had to stay at my house. The social worker told us to look for a place. We wanted a good, homely, caring atmosphere. She gave us the names of some homes and we came unannounced. The manager dropped what she was doing and showed me around. We went around and asked questions but really were looking for good care and attitude. We watched and it was very homely and knew it would suit mother. That is why I picked it. They came and assessed her – with another lady. They asked a lot of questions and I think they got enough information to determine if they could meet her needs. The process of moving in was absolutely fine and they told me I could come any time I liked. They gave me a lot of information about how they could meet her needs and keep her stimulated”. The assessment process helped family members and residents feel comfortable with entering a care home Resident’s case tracked said, “It’s a nice room. I have a few personal things in my room. I like to share my room with my friend” and “I like my room – its nice and I have some of my own things”. A visitor said, “Her room is the best in the house”. The homely atmosphere was satisfactory to residents and their families. Residents case tracked said, “The girls treat us very well” and “The girls are very nice – they have a laugh with us. The care is good”. One visitor said, “Staff are lovely and it’s the last thing I have to worry about. The owner is very nice”. The professional attitude of managers and staff gave residents and family’s confidence in the care they received. Resident’s case tracked said, “The food is good – its all right” and “The food is very nice”. One visitor said, “I have had meals here and they are very nice. She was not eating at home and now she is eating regularly”. Residents appreciated the meals served at the home. A visitor said, “There is autonomy within the home – she has choices – she can get up or stay in bed. When they get up they can have breakfast at any time”. Plans of care encouraged staff to give residents choices. The choices within the routine of the home allowed residents to remain independent. Resident’s case tracked said, “My family come when they want” and “My daughter came this morning – there are no problems with visiting”. One visitor said, “There are no problems with visiting – we can make our own cuppas”. Visiting was encouraged to aid the social inclusion of residents. Resident’s case tracked said, “They look after us I feel safe. I would talk to the manager if I had a worry” and “I would talk to my daughter if I had any problems. I feel safe here”. A visitor said, “I have a complaints procedure at home and it has your address on. I think she is as safe as she can be”. The open attitude of staff allowed residents and their families to feel protected. Towneley House DS0000009456.V346926.R01.S.doc Version 5.2 Page 7 One visitor said, “They took mother to Benidorm and she thought it was ace”. The range of activities offered gave residents something to talk about and enjoy. One visitor said, “They have discussed her care with me. I gave them a resume of her needs and they have tried to accommodate her. They did not twist her arm but very gradually they have helped her get to bed, which she did not at home. They inform me of any medical or important issues. She is now much happier. She was in a single room but found a friend and they share it. I am very happy with the home”. Families were kept up to date on important issues and staff understood the importance of family involvement. What has improved since the last inspection? What they could do better: The registered person should ensure the last wishes of residents are documented to meet the needs of residents who are dying. The registered person should ensure risk assessments conducted upon residents contain the necessary information for staff to follow to provide good outcomes for residents. The registered person should ensure tissue viability and nutrition are assessed using a recognisable tool to protect the health and welfare of residents. The registered person should ensure the results of quality assurance surveys are summarised and made available for inspection to provide interested parties with the information. Towneley House DS0000009456.V346926.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. Towneley House DS0000009456.V346926.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 Towneley House DS0000009456.V346926.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): OP3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment process ensured each residents needs could be met and a plan of care developed. EVIDENCE: Three residents were case tracked. Assessment documentation was contained within the plans of care. There was either an assessment from social services or health care professionals. A member of staff had carried out a preadmission assessment to ensure staff had sufficient knowledge to care for residents admitted. Intermediate care was not provided. Towneley House DS0000009456.V346926.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): OP7, OP8, OP9 and OP10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Plans of care and healthcare assessments contained sufficient information about each individual to inform staff of each residents needs. Medication policies, procedures and staff training protected the health and welfare of residents. The attitude of staff protected the privacy and dignity of residents. EVIDENCE: Three residents involved in the case tracking process had a plan of care. Plans of care had been regularly reviewed and developed with residents or their families. Two staff members were able to accurately describe the care of resident’s case tracked. Two residents involved in the case tracking process agreed the level of care was what was expected. One visitor spoken to in depth was extremely satisfied the care was exactly what her mother needed. Plans of care were detailed although areas for improvement were to provide better outcomes for risk assessments. Plans of care should provide information about resident’s last wishes. Plans of care contained sufficient information for staff to deliver effective care. Towneley House DS0000009456.V346926.R01.S.doc Version 5.2 Page 12 Plans of care contained details of attendance to health care professionals and specialists, such as psychiatrists, opticians, dentists and chiropodists. Plans of care contained risk assessments for falls but needed to use a recognised tool for tissue viability and nutrition to ensure best practice. One visitor confirmed access to specialist help was arranged at the care service. Access to specialists was arranged to ensure the health care needs of resident’s was met. Trained staff administered medication. Policies and procedures for the administration of medication had been reviewed using the Royal Pharmaceutical Societies Guidelines. There was a controlled drug cupboard and register although no residents currently took controlled drugs. There was a dedicated fridge to keep medication cool. The medication administration charts had been maintained accurately. An up to date British National Formulary was available for staff to use for reference to medication issues. The registered manager said the pharmacist was available for training and advice and regularly audited the system. Medication was disposed of in a safe manner. Medication policies, procedures and staff training helped reduce the risk of any medication errors. The inspection was mainly conducted from a communal area to observe staff interacting and caring for residents. Staff were observed to give care in a pleasant and private manner. The demeanour of staff ensured residents were comfortable with the personal care they received. Towneley House DS0000009456.V346926.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): OP12, OP13, OP14 and OP15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Leisure activities provided were suitable to resident’s tastes and helped provide a fulfilling life. Visiting was open, unrestrictive and encouraged socialising with family and friends. Residents were able to exercise choice to retain some independent living and food served at the home met their nutritional needs. EVIDENCE: On the first day of the inspection several residents were going on a trip in the homes mini-bus. They went going for a ride round and then for a drink. A trip was arranged every Wednesday. On the day of the inspection residents were listening to music and singing. Staff tended to join in after a while making a very pleasant atmosphere. In the other lounge residents were chatting or watching television. Many activities and outings are held at this home including the trips, holidays (several residents had been to Benidorm), music and singing; entertainers attended the home about twice a month, movement to music provided by an external source weekly. The registered person said, “We use personal choice planning and look at individuals wishes and dreams, then make steps towards it. We take three men to a driving range for golf. Go out for lunch and for drinks. Sometimes we have drinks in the evening. Some residents go to a football match at Burnley. We go on outings for special Towneley House DS0000009456.V346926.R01.S.doc Version 5.2 Page 14 occasions such as a Christmas meals etc. One resident went shopping yesterday. We take people shopping for clothes to Bury market or major stores. We especially need to go shopping for holidays – tops and shorts are not normally part of the wardrobe. We do play bingo, dominoes and have quizzes for stimulation. I am sometimes wary of remembrance therapy because it can disturb them. We also have large floor games, go to theatres and local seaside places for picnics such as Blackpool”. The range of leisure activities provided residents with a fulfilling life. During the case tracking process three care plans showed how staff could offer choices to residents. Within the plans residents were encouraged to be independent and where possible staff played an encouraging role rather than doing. Choice was offered within aspects of the routine such as dressing, getting up and going to bed, activities or food and drink. Residents chose the times they got up and went to bed. On the day of the inspection one resident wished to stay in bed and did not participate in the case tracking process. Residents were allowed choices to help them retain some control over their lives. Resident’s case tracked said food was good. Other residents were observed eating and said they enjoyed what they had eaten. A meal was taken by the inspector and found to be hot, nutritious and tasty. A visitor said food was good. Residents were observed being fed in an individual and discreet manner. The kitchen was clean and tidy. The cook held a relevant qualification and environmental health checks had been undertaken. Residents were satisfied with the choice and quality of food at mealtimes. Towneley House DS0000009456.V346926.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): OP16 and OP18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies, procedures and staff training help protect residents from possible abuse. Residents and their families were able to voice their concerns. EVIDENCE: There was a complaints procedure, which met current timescales and satisfied the requirements of the CSCI. No complaints had been made to the CSCI during the year since last key inspection. One visitor said staff were approachable. The complaints procedure was accessible for relatives and visitors. Staff were aware of the complaints procedure. The registered person thought her regular availability helped by dealing with minor issues at an early stage. There was a system in place for residents and relatives to complain if they wished. There had been no incidents of abuse since the last key inspection. There were adult abuse procedures for staff to follow. Although on a residents behalf but not directly involving the home the registered person had experienced the abuse procedures. There was a whistle blowing policy and a copy of the ‘No Secrets in Lancashire’ document. Policies and procedures protected residents from possible financial abuse. Some staff had undertaken Protection of Vulnerable Adults training. The systems used for the protection of vulnerable adults protected residents from possible harm. Towneley House DS0000009456.V346926.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): OP19 to OP26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents lived in a clean, tidy and safe environment. The facilities provided a comfortable setting and met resident’s environmental needs. EVIDENCE: A tour of building was conducted on the day of the inspection. The home was warm, clean and free from offensive odours. Several bedrooms were inspected and found to be bright and contained good levels of furniture. All bedrooms visited had been personalised. Water temperatures were checked and were around 43 degrees C. Windows were secured and radiators guarded against possible scalding. There was a stair lift to access the upper floor. The dining room and lounge contained sufficient, good quality furniture to meet resident’s needs. All furnishings were domestic in character. Lighting was sufficient to meet the needs of residents some were observed reading. Grab Towneley House DS0000009456.V346926.R01.S.doc Version 5.2 Page 17 rails and disability equipment was provided in all the necessary areas. One bath was suitable for the disabled. There were good levels of equipment for leisure, including large televisions and music systems. There was no dedicated storage of wheelchairs but this did not pose a threat to the health and safety of residents. There was a system of routine maintenance. Residents were risk assessed to determine if they can hold a key to their rooms and all have a lockable space. Keypad locks stop residents from absconding and being at risk of an accident. There is a small garden area and residents can sit outside and eat. Carpets had been replaced in areas where recommendations had been made at the last inspection. The suitable décor and domestic style setting provided a homely atmosphere for residents. There were infection control policies and procedures for staff to follow. The laundry was sited away from the kitchen and contained sufficient equipment to meet its purpose. Hand washing facilities were sited where clinical waste was produced. The laundry walls and floors could be cleaned easily. Some staff had received infection control training. Infection control policies, procedures and staff training helped protect the health and welfare of residents. Towneley House DS0000009456.V346926.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): OP27, OP28, OP29 and OP30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were sufficient numbers of qualified and experienced staff to meet the needs of residents. The recruitment procedures protected residents from possible abuse. EVIDENCE: The staffing rota showed there were sufficient numbers of staff on duty on the day of the inspection. Two residents case tracked and one visitor was happy with the caring attitude of staff. Staff files contained records of training undertaken. Staff received recognised induction training. Two staff files demonstrated training was ongoing and staff were appraised and supervised. Both staff members involved in the inspection process confirmed sufficient training was offered and they were encouraged to improve and provide a better service to residents. Two staff files examined during the inspection demonstrated the recruitment procedures were robust and ensured staff were fit to be employed at the care service. Towneley House DS0000009456.V346926.R01.S.doc Version 5.2 Page 19 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): OP31, OP33, OP35 and OP38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of residents, staff and stakeholders had been obtained to assist the manager to react to the changing needs of residents. There was a safe system to protect residents from possible financial abuse. Health and safety policies, procedures, staff training and the regular maintenance of equipment helped protect the health and welfare of residents and staff. EVIDENCE: The registered manager had completed NVQ training. She had updated her knowledge since the last key inspection by completing courses on dementia care and other suitable training. There was a suitably qualified and experienced manager to provide guidance to staff. Towneley House DS0000009456.V346926.R01.S.doc Version 5.2 Page 20 The systems used to handle any residents finances were safe and protected residents from possible financial abuse. There was a business plan. The manager held recorded meetings with residents and staff and met with relatives on a regular basis. Quality assurance questionnaires had been issued to residents, relatives and other professionals and the manager was producing the results as a summary for interested parties. Comments were very positive about the care offered and facilities provided. The quality assurance system used enabled management to react to the changing needs of all concerned with the home. There was a health and safety policy. Staff spoken to said they had undertaken health and safety related training. Electrical and gas appliances and installation had been maintained to a good level. Fire alarms and other safety related equipment had been maintained. The responsible person was aware of health and safety related issues. Health and safety policies, procedures and staff training helped protect the health and welfare of residents. Towneley House DS0000009456.V346926.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Towneley House DS0000009456.V346926.R01.S.doc Version 5.2 Page 22 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 OP7 Good Practice Recommendations The registered person should ensure each residents last wishes are recorded for staff to follow and carry out. The registered person should ensure all risk assessments conducted upon residents contain the necessary information for staff to follow to provide good outcomes for residents. The registered person should ensure tissue viability and nutrition are assessed using a recognisable tool to protect the health and welfare of residents. The registered person should ensure the results of quality assurance surveys are summarised and made available for inspection. 3. 4. OP8 OP33 Towneley House DS0000009456.V346926.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Towneley House DS0000009456.V346926.R01.S.doc Version 5.2 Page 24 - 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!