Inspection on 01/05/07 for Townend Close

This inspection was carried out on 1st May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Townend Close 20/02/06

Townend Close 14/11/05

Townend Close 25/01/05

Townend Close 15/07/04

Townend Close 27/01/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Townend Close Victoria Road Crosshills Keighley West Yorkshire BD20 8SZ Lead Inspector Caroline Long Key Unannounced Inspection 1st May 2007 09:30 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 Townend Close DS0000007962.V335807.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. Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Townend Close Address Victoria Road Crosshills Keighley West Yorkshire BD20 8SZ 01535 634639 01535 631067 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) sharon.blackwell@anchor.org Anchor Trust Mrs Jill Wiseman Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th February 2006 Brief Description of the Service: Townend Close provides personal care and accommodation for up to 39 older people and is owned and managed by Anchor Trust. The home is a detached property that is purpose built and is next to a sheltered housing scheme. It is near to local amenities in Crosshills and the towns of Skipton and Keighley are a short drive away. The accommodation is spaced over two floors and all the rooms have a bedroom/living room, a kitchenette and a bathroom and their own front door with a bell and letter box. For communal use, there is a lounge and dining room, and five assisted bathrooms. There are enclosed gardens to the rear where residents can sit out in the summer, and a large car park to the front. The Statement of Purpose and Service User Guide are provided upon enquiry. The cost of a placement at the home is dependent on individuals needs. Currently charges range from £480 to £525 per week. The cost to the resident is dependent on the level of Local Authority funding and benefit entitlement. Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence used in this report has included: • • • • A review of the information held on the homes file since its registration. Information submitted by the registered manager in the pre inspection questionnaire. Surveys received from eleven residents, seven relatives, a care manager, a health professional and a general practitioner. An unannounced visit by an inspector to the home lasting over seven hours. This visit included a tour of the premises, examination of records; talking to four residents, care staff, an activities coordinator and management. Looking at three residents care files in detail. • What the service does well: Many positive comments were made by residents and their relatives about Townend Close; for instance, ‘If you cannot be at home it is a lovely home to be in,’ and ‘I have nothing but good to say.’ Residents are provided with enough information and given the opportunity to stay at the home before they move in permanently. This helps them make an informed decision about whether Townend Close is the right place for them to live. Residents are encouraged to be independent and make choices about how they want to live their lives. Staff are sympathetic to residents needs and are dedicated to making sure residents individual health care needs are met. Staff have good relationships with the health care professionals. The home has a warm friendly atmosphere, where residents are encouraged by staff to participate in social activities of their choice. There are various outings arranged and in house activities, which allow residents contact with the local community and provide stimulation. Visitors are encouraged and made welcome. Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 6 Townend Close is very clean and comfortable and contains the adaptations necessary to meets the residents’ individual needs. This enables the resident to remain independent. 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. Townend Close DS0000007962.V335807.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 Townend Close DS0000007962.V335807.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): Standard 3. People who use the service experience excellent quality outcomes in this area. People are provided with good information about the home and their diverse personal needs are identified and planned for before moving in, this make sure the Townsend Close is the right place for them to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The deputy manager explained a member of the management team visits the prospective resident’s at their home to carry out an initial assessment of their needs and to provide them with information about Townend Close. Following this, residents are invited to visit Townend Close for a week’s stay to see if they like it. During the week’s stay a detailed assessment of the residents needs are carried out. Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 9 Two residents’ records who had recently been admitted to the home were looked at in detail; both contained a brief initial assessment that had been carried out in residents’ homes and a more detailed assessment, which had been carried out during their weeks stay in the home. This information was comprehensive, had the necessary details to give a good indication of the residents’ care needs, promoted their independence and showed the residents had been fully consulted. Residents explained the different ways they had come to live at Townend Close, one had a friend in the home that they had visited who had recommended the home. Another came straight from hospital, and one had stayed at the home temporarily when they were not well enough to manage alone following an illness. However, all these residents and those who responded to the surveys stated they felt they had been very well informed about their move into the home, and made very positive comments. For instance: ‘The staff had been most kind, they checked on me to make sure I was comfortable when I first came in.’ ‘I came in for two weeks respite and liked it so much I decided to stay.’ ‘I came to stay for three times before I made up my mind to stay permanently.’ Health professionals also made positive comments about their experience of placing residents in the home. Examples are: ‘I placed a person for a respite stay their general health deteriorated. The staff were very prompt in alerting health professionals and myself.’ ‘Great with people on arrival make them welcome, listen to what is requested.’ The deputy manager gave an example how residents’ needs were always reassessed when the staff did not believe they could meet all their care needs. During the site visit residents said they felt they were in ‘safe hands’, and the staff said they had received enough training to enable them to meet all of the residents’ needs. The home does not offer intermediate care. Townend Close DS0000007962.V335807.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): Standards 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. Residents are receiving their health and personal care based on their individual needs and choices. Staff are practicing principles of respect, dignity and privacy when supporting residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been many positive comments made by residents both on the surveys and during the site visit. Examples are: ‘Lovely if you can’t go home, this is my home.’ ‘I have nothing but good to say.’ ‘I receive more care than I expected.’ Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 11 ‘I do a lot for myself but when I need help the carers are always there.’ Three care records were looked at in detail, they all contained ‘lifestyle plans’ which were comprehensive, identified the individual residents personal needs, showed evidence of the resident making choices and their involvement. The plans covered aspects such as daily living, cleaning, catering, spiritual, cultural and religious needs, pets, social activities and medication. They clearly described how residents wanted their lifestyle to be and how their independence was promoted. These were supported by risk assessments, which described the possible risks to the residents, and the actions the staff needed to take to minimise these risks. Both the care plans and the risk assessments had been reviewed regularly. However these documents were cumbersome and not very user friendly and although residents described how staff would discuss their care regularly, they were not clear about the written care plans. Residents discussed how staff promoted their dignity and treated them with respect during the site visit. Examples given were how staff asked what name the resident preferred to be called or how staff always draw the curtains before helping them with personal care. However, during the site visit poor practice was observed, which did not promote a residents dignity. This was shared with the management who agreed to take the actions necessary to resolve this. Many positive comments were made by relatives about the care the residents received for instance: ‘Residents are able to maintain as much independence as possible with more help when it is needed.’ ‘I think this home has responded well to relatives changing and sadly deteriorating needs. They are usually open to suggestion regarding their care.’ ‘My relative has been at Townend Close for a few years and my family consider ourselves lucky that we can feel that they are well looked after and happy there.’ Resident’s health care needs are promoted and maintained. When a resident is, admitted their nutrition, skin and dependency needs are assessed and if the assessment indicates any specialist needs these are monitored, added to their care plans and a referral is made to the appropriate health professional. The records showed residents were accessing health care professionals, such as GP’s, Chiropodists, and District Nurses. The residents and relatives surveys also confirmed they receive the medical support they need. However, one did state that a resident had missed a dental appointment and their reading glasses had been lost. Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 12 One health professional commented: ‘they provide an excellent standard of care to a variety of individuals meeting their diverse needs in a professional manner. They promote residents privacy and dignity. There is a medication procedure to guide the staffs practice and training is provided on safe storage, administration and disposal of medicines. Also, where possible, residents are encouraged and facilitated to keep and take their own medication. However, there is insufficient storage space for the amount of medication the home stores and dispenses and no system in place to make sure the right amounts of medication have been given. During the site visit the deputy manager agreed to review the medication practices. Townend Close DS0000007962.V335807.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): Standards 12, 13, 14 and 15. People who use the service experience excellent quality outcomes in this area. Residents have the lifestyle they choose. Staff provide opportunities for residents social, cultural and recreational expectations to be met and residents have a varied diet, according to their choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Townsend close has a full time activities coordinator, who works flexible hours to enable her to make sure residents’ activities are held both on an evening and at weekends. Care staff assist her to provide a range of group activities and outings for the residents, such as bingo, slide shows, parties and a trips to local events. Residents’ lifestyle plans contain information about their preferred activities and past times and the coordinator meets with each resident to discuss their social interests. Where she identifies a particular need, such as the need for Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 14 wheelchair accessibility at an outside venue, before taking the resident she will find out about the best possible route for the resident. The service users guide states relatives are able to visit as they please and offers refreshments, such as a meal for £2.50. Relatives were observed visiting resident during the site visit. There is regular church service in the home and a magazine or bulletin about the home, which includes information about activities and articles about staff and residents. Comments made by residents both during the site visit and from the surveys, confirmed residents make a choice about their daily life and social activities. ‘I always join in most activities and enjoy them.’ ‘I like to go on a few trips out not all of them and I like to go to in house entertainment.’ ‘Sometimes – It is my choice that I do not always take part in any activities. I join in with the things I like to do.’ Relatives commented: ‘We particularly like the freedom that my relative is given to go for short walks on her own. This has given my relative a new lease of life.’ ‘The light touch my relative needs, they organise contact with the local church which has meant my relative can maintain her church attendance which is very important to her.’ However, two relatives did comment that there was not always enough activities in the home, particularly for people who could not join in group activities but needed one to one support. During the site visit and on the surveys residents said the food was generally very good. The deputy manager explained there had been some problems with the quality of the food provided to residents but this had been resolved and residents’ now said the food was good. This was reflected in the comments made on the residents’ and relatives’ surveys. In the dining room there is a juice and water dispenser which the residents can use as they please. All of the residents’ also have a small kitchen area in their rooms where they can make there own drinks and food if they wish. Residents’ can order tea, coffee, milk; butter etc to have in their room and meals can be served in their rooms on request. Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 15 In the dining room meals were treated as an occasion, tables were set with table clothes; napkins, flowers, and vegetables were served in tureens. Although the dining room was slightly cramped when all the residents were taking lunch, it did have a relaxed and happy atmosphere. The deputy manager explained the dining room is to be extended in the near future to accommodate the residents better and to increase the space for wheelchair users. Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the service experience excellent quality outcomes in this area. Residents have access to an effective complaints procedure and are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is given as part of the service user guide, which residents keep in their room. All residents surveyed said they knew whom to complain to comments made were: ‘I would tell you’, ‘the staff’ or ‘the manager.’ During the site visit, residents were seen to be comfortable approaching the deputy manager and staff and making their views known. The residents spoken with also said they felt comfortable to approach the managers and staff with any complaints. Residents’ have regular residents’ meetings and before the meeting, the co-ordinator talks privately with each resident and asks if they would like to put any concerns on the agenda. Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 17 There have been no formal complaints to the Commission. The deputy manager explained any major complaints are dealt with by Anchor’s head office, which employs an independent arbitrator to investigate complaints. The management have recently commenced recording minor concerns and how they are resolved in a logbook. There were three recorded which covered missed appointments, communication and staff attitude, all had been resolved. To meet with confidentiality and data protection separate records for each concern should be kept with a log to track where the details are held. There is a comprehensive policy and procedure with regard to safeguarding adults and the procedure to take if there is a suspicion of abuse. The deputy manager and staff were aware of the actions to take to safeguard adults. Residents said they felt ‘safe’ in the home Staff have received training in adult protection and safeguarding issues during induction and their National Vocational Qualification in care. The deputy manager explained further training was to occur soon about safeguarding adults. Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. People who use the service experience excellent quality outcomes in this area. The residents live in a very clean, safe, well-maintained and comfortable environment This judgement has been made using available evidence including a visit to this service. EVIDENCE: Townsend Close was designed for assisted living; all the rooms have a bedroom/living room, a kitchenette and a bathroom. For communal use, there is a lounge and dining room, and five assisted bathrooms. Each unit has a front door, letterbox and bell. The home has wide corridors, which enables easy passage of two wheelchairs. There are enclosed gardens to the rear where residents walk or can sit out in the summer. Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 19 The deputy manager and hospitality manager explained the home is being refurbished. Many of the bedrooms in the home have been refurbished and the kitchenette and lounge/bedroom have been joined to make one large living area. The communal dining room is to be extended to improve wheelchair accessibility in the autumn. Some of the communal bathrooms have also had new assisted baths fitted. Three resident rooms were visited all contained personal possessions which were age and cultural appropriate to the resident. All said their rooms were ‘very good’ or ‘the best’. During the site visit the home was found to be exceptionally clean and fresh. In the entrance there is a beige carpet, which is used all the time but is spotless, the cleaner explained this carpet is cleaned weekly. This high standard of cleanliness and presentation was found throughout all the areas of the home visited. Residents surveys also said this was normally the case comments made were: ‘The home is always lovely fresh and clean’ ‘I can not find fault with clean’ ‘Yes it is very fresh and clean, Very impressed.’ The home had the adaptations and equipment necessary to enable residents to maintain independent daily lives. Residents’ have a kitchenette where they are able to make hot drinks and prepare snacks if they want. One of resident who uses a wheelchair has had a key pad lock installed on the front door to enable them to open it without the help of staff. The home has a handyman who carries out maintenance work and carries out the health and safety checks. Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. Staff in the home are generally trained, skilled and sufficient in numbers to meet the needs of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Many positive comments were made about the staff by the residents: ‘staff are very helpful, friendly and respectful’ ‘they are kind and obliging and answer the call bell quickly’ ‘Most of the staff are very good.’ Although one did write: ‘Some of the care staff are very good and some are not so good sometimes they do not always listen to what I am saying’. Residents can nominate staff for a ‘above and beyond certificate’ where they believe the staff have carried out work above the level of duty. Three staff had Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 21 been nominated recently for staying during the night with a resident who was terminally ill. Staff and residents said there was generally enough staff on duty to meet the needs of the residents. Residents said call bells were answered promptly and staff explained that many residents are quite independent and so they are able to manage. However, where a resident needed one to one time this could not always be met. The home generally operates from Monday to Friday with four members of care staff and a manager during the day, and two overnight, at the weekend the rota shows the number dropping to three and a manager. The care staff are also supported by the receptionist, dining room assistants, laundry assistants and the activities coordinator. Staff confirmed they have received induction training and where they had worked at the home for a number of years their training had been up dated. Training they had attended was mobility assistance, dining with dignity, health and safety, medication, fire, and protection of vulnerable adults. Residents generally said they felt ‘safe’ and that most staff were knowledgeable about their work. The pre assessment questionnaire shows 59 of care staff have their National Vocational Qualification Level two or above in care. Four staff records were looked all contained the information and checks necessary to protect residents from abuse. The deputy manager explained residents did take part interviewing staff for the home. The deputy manager explained the registered manager receives written notification from the head office about the results of the police check but this does not contain details of any convictions. Where a police check gives details of a conviction the reasons for the decision to employ should be recorded on the staff file. Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. Residents needs are met due to the good management and administration of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit all the staff and residents said the management were approachable and supportive. Townend Close has an experienced registered manager who has her Registered Managers Award and National Vocational Qualification Level Four in care; a deputy manager, a hospitality manager and team leaders support her. Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 23 Residents’ have regular meetings and the activities coordinator approaches each resident individually to ask if they would like to raise anything on the agenda. Anchor Homes, carries out an annual survey of residents and relatives where it asks their view about the home, this covers area such as physical environment, care and service, complaints and staff roles, the results of this are published and made available to the residents. The deputy manager explained where residents want the home to keep money for them, all transactions are recorded, and receipts are kept and money is held in a locked cabinet. The information in the pre assessment questionnaire confirmed that equipment is maintained; gas and electricity supplies in the home are safe and serviced appropriately. Fire detection and fire fighting equipment is tested and maintained and staff are regularly trained. Health and safety staff team meetings are carried out monthly. Records showed accidents were responded to and recorded in a ring binder file. To meet with confidentiality and data protection separate records for each accident should be kept with a log to track where the details are held. Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 24 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 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 X X X X X X 4 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 X 3 X 3 X X 3 Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 25 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 Refer to Standard OP9 Good Practice Recommendations To prevent mistakes from being made the monitoring and storage of the medication should be reviewed to investigate how this could be made safer. To meet with confidentiality and data protection separate records for each concern should be kept with a log to track where the details are held. To meet with confidentiality and data protection separate records for each accident should be kept with a log to track where the details are held. 2 OP16 3 OP38 Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Townend Close DS0000007962.V335807.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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