Inspection on 26/07/07 for Truscott Manor

This inspection was carried out on 26th July 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

Truscott Manor 16/05/06

Truscott Manor 19/12/05

Truscott Manor 03/06/05

Truscott Manor 23/11/04

Truscott Manor 25/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Truscott Manor Lewes Road East Grinstead West Sussex RH19 3SU Lead Inspector Mrs D Peel Unannounced Inspection 10:05 26th July 2007 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 DS0000024231.V341563.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. DS0000024231.V341563.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Truscott Manor Address Lewes Road East Grinstead West Sussex RH19 3SU 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) 01342 314458 01342 317240 info@truscott.wanadoo.co.uk Frannan International Limited Mrs Caroline Joan White Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places DS0000024231.V341563.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May admit one service user between the age of 60 and 65. Date of last inspection 24th October 2006 Brief Description of the Service: Truscott Manor is a care home able to provide nursing care and accommodation for 41 people in the category of older people. Frannan International Ltd is the registered provider and the Responsible Individual on behalf of the company is Mrs N. Kassam. The home is located in a rural setting in extensive grounds on the outskirts of East Grinstead, shops and other amenities are a short drive away. Private accommodation is on two floors, a passenger lift is available but does not serve all rooms. Communal accommodation is available on the ground floor. The majority of the homes bedrooms are single and 19 have en-suite facilities. The fees currently being charged by the home are from £545 to £700 DS0000024231.V341563.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit to Truscott Manor was carried out by Mrs Diane Peel on the 26th July 2007. During this visit the intended outcomes for 33 standards were assessed; these included the key standards for care homes providing a service to older people. Since the last Key Inspection carried out in May 2006 an additional visit was made to the home in October 2006 to ensure that Statutory Requirements made as a result of the May 2006 visit had been carried out. At the visit in October 2006 all but four Statutory Requirements had been met satisfactorily and the remaining four were carried over as outstanding Statutory Requirements to be met by December 2006. Prior to this unannounced inspection the inspector reviewed, previous inspection reports, information gathered about the home, including an action plan and letter from Mrs Kassam assuring the Commission for Social Care Inspection (CSCI) that outstanding Requirements from the October 2006 had been met. Nine Have Your Say questionnaires were returned from people living at the home, ten relatives surveys, two Doctors surveys and one Social Care professional survey were also returned prior to the visit and were used to substantiate judgements made throughout the inspection process. The Annual Quality Assurance Assessment (AQAA) was returned to The Commission for Social Care Inspection (CSCI) prior to this visit to the home and this was used to address areas of improvement, which had been made and further improvements, which the manager thought could be made. On the day of the visit there were thirty-four people living at the home and during the course of the visit the inspector met some residents in the privacy of their rooms or chatted to others in the lounge. Staff were spoken with informally during the visit and observed during their interaction with people living at the home and one visitor to the home took the time to discuss their opinion of the care service being provided. No Statutory Requirements were made as a result of this inspection. What the service does well: DS0000024231.V341563.R01.S.doc Version 5.2 Page 6 People living at the home and their representatives say that a good standard of care is delivered by caring professionals who are cheerful, polite and respectful of peoples privacy and dignity. The home provides a friendly homely environment and atmosphere, which encourages visitors and people living at the home to feel at ease. The manager has built up good relationships with other stakeholders and promotes the best possible care for the people living at the home. The best possible care is promoted for those people nearing the end of their lives with advanced care plans being drawn up with residents and significant others and the support of local hospice nurses. What has improved since the last inspection? What they could do better: DS0000024231.V341563.R01.S.doc Version 5.2 Page 7 There are already plans in place to ensure that people living at the home are aware of the choices of food available to them but this was an area, which was mentioned in surveys returned to CSCI as an area for improvement. Further improvements should continue to the décor of the home and this as been acknowledged by the manager and registered provider. 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. DS0000024231.V341563.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000024231.V341563.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,5,6 People who use the service experience good outcomes in this area. People, who come to live at the home and their families, have information available to make an informed choice about where they want to live and people’s needs are assessed before they move to the home, so that they know that the home can meet those needs. EVIDENCE: The Statement of Purpose and Service User Guide was observed to be on display in the entrance hall and it contained the most recent inspection report. Bedrooms were visited at random and it was observed that many had a copy of the Statement of Purpose and Service Guide present, which also directed people to the location of the most recent inspection report. DS0000024231.V341563.R01.S.doc Version 5.2 Page 10 People living at the home spoken with during the visit spoke about the process of choosing a care home and for most they had had a relative visit a selection of homes for them. From the information gathered through Have Your Say Questionnaires returned to CSCI, seven out of nine people reported that they had had enough information about the home before they moved in to make a decision if it was the right place for them. One person said in their returned questionnaire “ my daughters came to look at the nursing home. They also spoke to people, whose family member was there. They were able to speak to some staff members”. A relative spoken with during the visit to the home spoke about visiting the home prior to their relative moving into the home. They had been to the home on a number of occasions in a professional a capacity which helped them to be sure that it was the right care home for their relative. The records of people living at the home were seen during this visit, which include records of two people who recently moved into the home. All included pre assessment documentation carried out prior to moving into the home. Information provided in the homes Annual Quality Assurance Assessment (AQAA) returned to CSCI prior to the visit to the home reported that there are both male and female care staff working at the home of various ages between eighteen years of age and sixty five years of age and who are from diverse social, cultural, and religious groups. The home does not offer intermediate care. DS0000024231.V341563.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People who use the service experience excellent outcomes in this area. Care planning systems are regularly updated and they give clear information to assist with all aspects of health, personal and social care needs so that the changing needs of people living at the home can be monitored. EVIDENCE: The care records and personal care plans for four people were viewed at this visit which included the records of two people who had recently moved into the home to see how the pre assessment and other information gathered during the process of admission to the home had been used to develop a plan of care. All records observed included a long term needs assessment, pressure care risk assessment, moving and handling risk assessment, falls risk assessment, nutritional assessment, and a plan of care which identified problems, care intervention and an expected outcome or goal. DS0000024231.V341563.R01.S.doc Version 5.2 Page 12 Care plans included social needs and included regular review details and evidence of routine monitoring of health e.g. weight and outcomes from visits by other healthcare professionals such as the Doctor. Out of the nine Have Your Say questionnaires returned to CSCI from people living at the home six people reported that they always receive the care and support that they need and two reported that they usually receive the care and support that they need. There was negative feedback from one person in the survey and this person spoke with the inspector during the visit to the home about their problems. From the same nine surveys eight people said that they always had their medical needs met and the same one person said that their needs were not being met. One person commented “ the doctors call to the home when they are needed and also the dentist came to see me as well and then I went to the dentist practice.” Two surveys were returned from Doctors who regularly visited the home, which gave positive feedback about the “excellent care” and “good senior care and management”. The homes own satisfaction questionnaires returned from Doctors showed a 100 satisfaction. A social worker returning a questionnaire to CSCI complimented the home on the level of complex needs being attended to but did suggest that more detail could be included in the care details of the review of care plan. The home has a policy for control, storage, disposal recording and administration of medication. The Annual Quality Assurance Assessment returned to CSCI reported that this policy had been reviewed in January 2007. Medication is stored in two locked medication trolley kept in the office. Only registered nurses administer medication and samples of initials of those people able to administer were observed in front of the medication record sheets. Only registered nurses were observed to take out medication to people living at the home on the day of this visit. People spoken with during the visit commented upon how caring and polite staff are and during the visit staff were observed to speak with people respectfully, knock on doors before entering rooms and use the dividing screens in double rooms. One relative returning a questionnaire to CSCI said, “ The home is run efficiently with the physical and psychological care of each resident the first DS0000024231.V341563.R01.S.doc Version 5.2 Page 13 concern. Self-esteem and privacy are maintained and personal choice is always offered. All staff show respect for the residents and visitors and are always polite and helpful.” DS0000024231.V341563.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People who use the service experience good outcomes in this area. People living at the home are encouraged to maintain contact with their family and friends so that they can satisfy their social and emotional needs and the social activity programme is flexible to cater for individual residents abilities and to offer variation to daily living. EVIDENCE: Truscott Manor has an activities co-ordinator who oversees a regular activities programme. This programme is not always delivered to groups of people living in the home but had been extended to individuals who wish to remain in their rooms or who do not like taking part in-group activities. The programme for July was observed to be on display in the entrance hall and although the co-ordinator was on leave for some days in July it was observed that some regularly activities such as visits by a physiotherapist, and a pianist. DS0000024231.V341563.R01.S.doc Version 5.2 Page 15 Other activities listed for July were: communion, midsummer tea party, tea tasting, art and colour therapy, exercises, skittles and quizzes. One person living at he home spoke about the piano playing and the church service taken by “ the Rector”. There is a shopping trolley, which the activities organiser also takes around the home for people to make purchases from. Another person who spoke in the privacy of their room talked about the physiotherapy that they did but also they didn’t like to be with other people for a long time so they didn’t take part in group activities and also chose to stay in their rooms for meals. The home has an open visiting policy and keeps records of visitors to the home. Visitors/relative meeting are held so that people have an opportunity to feel part of the home. A comment received in the Have your Say Questionnaires returned to CSCI was “ The staff make relatives feel welcome and are warm and friendly. This is most important and one never feels a nuisance or in the way.” A visitor spoke with the inspector during the visit to the home and commented upon how friendly and helpful the staff were and although their relative had only been at the home for a short time, how pleased they were with the home. From feedback in surveys returned to CSCI from relatives and friends it was evident that relatives are made to feel welcome, they have regular access to management and feel included in the care of the care of their relative living at the home is situated. Professionals also visiting the home who returned surveys also commented about the “open door policy.” Results of the homes own quality assurance questionnaires observed at this visit showed that 34 of people living at the home who returned the surveys were very satisfied with the quality and choice of food, 60 said that they were quite satisfied with the food and 6 said that they were not satisfied with the food. DS0000024231.V341563.R01.S.doc Version 5.2 Page 16 The majority of people returning Have Your Say questionnaires to CSCI reported that they sometimes likes the food and from comments made it was not about the quality of what was being served but the choices available. This was discussed with the manager who said that there was always a choice at the main meal of the day and supper but it seemed that the choices were the problem in that the alternatives were usually the same. To try to rectify this problem a new system is already planned where at lunch time there will be two main meals on the menu and then fewer alternatives, which will be varied more often. This will initially be a trail to see if there is better feedback from people living at the home. The cook also spoke about menu choices and also confirmed the trial menu, which was planned. Menus observed in the kitchen did show plenty of choices especially at suppertime when there were always two soups, a variety of sandwiches and a cooked supper. There were plenty of food supplies observed in the fridges and food storage areas, which included fresh fruit and vegetables. DS0000024231.V341563.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People who use the service experience good outcomes in this area The complaints procedure enables those using the service to have the confidence that any complaints will be taken seriously and responded to. Arrangements are in place to protect people using the service from being place of harm or abuse. EVIDENCE: The homes complaints procedure is on display in the home ands included in the Service User Guide. CSCI has not received any complaints in respect of this service since the last visit to the home. The AQAA received prior to the visit to the home recorded that three complaints had been received in the last twelve months none of which had been substantiated. The complaints record was examined during the visit to the home that demonstrated the complaints had been responded to appropriately. DS0000024231.V341563.R01.S.doc Version 5.2 Page 18 All but one person living at the home who returned surveys to CSCI reported that they knew how to make a complaint and all relatives returning surveys said that they knew how to make a complaint. Truscott Manor Nursing Home has its own safeguarding adults procedure, which it uses in conjunction with the West Sussex Multi Agency Adult Protection Procedures. Induction records show that as new staff start work at the home they undertake an induction programme which includes information about how to recognise abusive situations and how to respond and report suspected abuse. To make sure that staff are ware of the policies and procedures of the home the manager takes one policy each week and has it as the “policy of the week”. Records showed that the Adult Abuse Policy had been the policy of the week twice recently. Staff records showed that people working at the home have supervised practice once the POVA first clearance had been received until a full CRB arrived. DS0000024231.V341563.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 People who use the service experience adequate outcomes in this area People living at the home are benefiting from an improved environment which they can enjoy and feel safe in and with a continuing redecoration programme in the home the registered provider can demonstrate a willingness to further improve the décor of the home. EVIDENCE: There have been continued improvements to the environment since the last visit to the home in October 2006. Not all-private accommodation was visited but the inspector visited twenty bedrooms chosen at random. All communal areas were observed. Bedrooms are being redecorated as they become vacant and furniture in bedrooms replaced this was evidenced in some of the bedrooms visited. This DS0000024231.V341563.R01.S.doc Version 5.2 Page 20 was confirmed by care staff and cleaning staff spoken with. People living at the home are encouraged to personalise their rooms with their own possessions and items of furniture. There are some double bedrooms in the home and all those observed during the visit had screens to use to maintain privacy and dignity. It was observed that a number of bedrooms had locks on them and staff spoken with confirmed that some people had chosen to have a lock. The manager confirmed that people who wish to have a lock could have one. Since the last visit to the home carpets have been replaced in the dining room, the corridors leading from the dining room and outside bedrooms 21, 22,and 23.Carpets had also been replaced in bedrooms 8,10 and 12a. The manager also commented that the carpets in the main corridor leading to the lounge were the next carpets to be replaced. Bathrooms and toilets observed were clean and had aids and adaptations so that residents can maximise their independence. The manager has now completed an audit of the lounge, discarded some furniture which was worn and purchased some new tables. Since the last visit to the home Mrs Kassam has confirmed that all radiators in the home are now covered and that the fire officers requirements have been met. During the visit to the home the inspector did not see any radiators not covered in rooms being used by people living at the home. Discussion with the manager and registered provider confirmed that the outside painting had been completed, corridors had been painted inside the home and there are plans to repair the driveway leading to the home. The cleaning supervisor spoke to the inspector about increased hours for cleaning the home and the major spring-cleaning programme, which had been taking place so that the day-to-day cleaning was easier to keep up to. It was observed that there was a noticeable difference to the cleanliness of the home, which had in the past been an area of concern. People living at the home who returned Have Your say questionnaires who made comments about the environment said: “ the home seems nice and clean.” “excellent “. “ the lady who cleans my room is very thorough and a friendly person.” “ there is lots of cleaning and hoovering all the time.” DS0000024231.V341563.R01.S.doc Version 5.2 Page 21 Comments received from relatives were: “ Because the building is old the exterior appears shabby in place, but the care within the home is what matters most and I can se that is very good.” “cleanliness is of a good standard.” “Truscott Manor provides a safe environment.” Results of Truscott Manor’s own quality assurance surveys showed that 30 of those people returning the surveys were very satisfied with the environment, 62 said that they were quite satisfied and 5 said that they were not very satisfied. DS0000024231.V341563.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People who use the service experience good outcomes in this area. Recruitment procedures safeguard and protect residents at the home. There is an ongoing training plan to make sure that staff have the combined skills to meet the needs group of residents. EVIDENCE: A rota was available in the home and the staff on duty was observed to be well organised and able to respond to the needs of people living at the home. Care staff are allocated to work in the three different areas of the home and trained nurses oversee them. There is a system in place to monitor the response times to call bells. Information provided in the AQAA returned to CSCI reports that all staff undertake the Skills for Care Common Induction Standards and that ten care staff have an NVQ at level 2 or above and that others are currently undertaking NVQ awards. The records of four staff were observed during this visit to the home, which included the most recently employed persons. DS0000024231.V341563.R01.S.doc Version 5.2 Page 23 They were observed to include evidence of Criminal Record Bureau (CRB) and Protection of Adults (POVA) checks. A job application was on file, two written references, photograph, proof of the person’s identity and completed equal opportunity monitoring forms and health declaration forms. Supervision and training records were available and evidence of further training already planned. On the day of the visit infection control training took place facilitated by an outside trainer. Comments about care staff received from people living at the home and relatives and visitors Were: “ The care staff appear to use hoists efficiently. They also appear to pay particular attention to cleanliness both of the clients and themselves e.g. use gloves and hand washing.” “All staff show respect for the residents and visitors and are always polite and helpful”. “There always seems to be a happy atmosphere amongst the staff and residents.” “The staff never fail to be cheerful and caring. They are very patient and are very quick to respond to alarm bells.” DS0000024231.V341563.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,37,38 People who use the service experience good outcomes in this area. People living at the home benefit from a well run home and are safeguarded by the homes policies, procedures and systems. EVIDENCE: The registered manager is Mrs Caroline White and she has worked at Truscott Manor since 1990. Mrs White is a registered nurse and is assisted by other senior care staff and administration support. The homes own quality assurance surveys returned to the home show that 72 of those people returning the surveys were satisfied with the DS0000024231.V341563.R01.S.doc Version 5.2 Page 25 management of the home, 22 were quite satisfied and 4 were not very satisfied. In addition to surveying people living at the home and their relatives the organisation surveys other stakeholders who visit the home such as Doctors, physiotherapists, chiropodist, Hairdresser, Palliative Care Nurses and Social Workers, to gain their views of the home. Questionnaires are also distributed to people after admission to the home to find out if the process of choosing the home could be improved. The home holds a small amount of money for a few people living at the home who might want to make a purchase from the shopping trolley which goes round the home. An expenses book is kept to record the purchases made. Any additional extras are invoiced directly to families of representatives. A supervision programme is now in place and records were available to evidence the ongoing supervision of new staff within the home. Information provide in the AQAA returned to CSCI showed the ongoing review of policies and procedures within the home and the manager has a “policy of the month “ which she goes through with staff. DS0000024231.V341563.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 3 2 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 X 3 3 3 3 DS0000024231.V341563.R01.S.doc Version 5.2 Page 27 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 OP19 OP15 Good Practice Recommendations Improvements to the décor of the home should continue Ways of ensuring that people are aware of the choices of food should be addressed. DS0000024231.V341563.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 DS0000024231.V341563.R01.S.doc Version 5.2 Page 29 - 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. 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