Inspection on 15/08/06 for The Manor House

This inspection was carried out on 15th August 2006.

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

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

Other inspections for this house

The Manor House 07/10/09

The Manor House 25/02/09

The Manor House 30/11/08

The Manor House 20/10/08

The Manor House 15/05/08

The Manor House 11/12/07

The Manor House 06/06/07

The Manor House 28/12/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Uphill Court 62 Uphill Road South Weston Super Mare North Somerset BS23 4TA Lead Inspector Nicola Hill Key Unannounced Inspection 09:30 15 & 16th August 2006 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 Uphill Court DS0000067101.V307157.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. Uphill Court DS0000067101.V307157.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Uphill Court Address 62 Uphill Road South Weston Super Mare North Somerset BS23 4TA 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) 0208 5606691 Shreyas S.A.I.N. Ltd Mrs Jana Harris Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25), Terminally ill over 65 years of age (25) of places Uphill Court DS0000067101.V307157.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Manager must be a RN on parts 1 or 12 of the NMC register. Staffing notice dated 26 May 1999 applies. May accommodate up to 25 persons aged 65 years and over. Date of last inspection Brief Description of the Service: Uphill Court is a registered care home with nursing; it is well established in the local community and sited close to local facilities. The fee level for the home is £450 per week for self-funded residential residents, rising to £600 per week for self-funded nursing care residents. Uphill Court DS0000067101.V307157.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection was undertaken with the manager Jana Harris, over a period of two days. Talking with the residents and relatives at Uphill Court, provided some of the evidence for this report. The inspector also reviewed care files for residents, and administrative records relating to the implementation of health and safety at Uphill Court. At the time of the inspection there were five vacancies at the home, however the manager had received several inquiries and had a planned admission. The inspector spoke with several residents, all of who were very complimentary about the lifestyle offered to them. Several of the residents had been at the home for some considerable amount of time. The inspector discussed the activities they were able to follow in the home, and observed an activity session. One resident talked about the visiting arrangements for her family, who she felt were made welcome by staff at the home and always offered refreshment. The inspector observed the staff at the home treating the residents with respect. At the time of the inspection the manager was in the process of organising a summer fair at home in order to provide residents with a social event, promote awareness of the home and the quality of care given at the home. The home is going through a period of change as it has been recently purchased by Shreyas S.A.I.N. Ltd. The manager is trying to ensure that there is stability at the home however the change of ownership is unsettling for both staff and residents as inevitably there will be changes. All of the staff and residents have been introduced to the new owner. The quality of the home has been judged as being good because the outcomes for residents based on evidence given by the residents and their relatives was positive and favourable toward the attitude and support given by staff. Some of the outcome groups have been judged as adequate and will need continued improvement so that the home will be able to retain their quality rating. What the service does well: The manager felt that the standard of care offered at the home was of a high quality, and that the home provides a continuity of person centred care for the residents. The quality of care provided at the home could be linked to the longevity of the residents there. The comments made by the residents were Uphill Court DS0000067101.V307157.R01.S.doc Version 5.2 Page 6 that they were happy at Uphill Court and lucky to be there, and that staff were very kind to them. They enjoyed the atmosphere at Uphill Court and had their personal preferences respected by the staff. The home has personal plans in place for all the residents at the home, which clearly identify any action needed to be taken by staff in order to, support the residents to be as independent as possible. The home also maintained good communication with the families of residents, to ensure that relationships are maintained; relatives confirmed this at the time of the inspector s visit. The relationships between the residents and staff are good and create supportive and caring environment, which promotes the security and well being of the residents. The home has a resident/relative committee in place so that service users have a forum for raising any issues; meetings are held on a two monthly cycle. There is also a suggestion box available for residents and visitors to use. The residents appeared to be well groomed, with coordinated clothing. The general atmosphere of the home was calm, with residents engaging positively with staff. All the residents have an allocated key worker who has responsibility to review care plans and to meet specific personal needs of their resident such as ensuring clothing is well maintained. The occupancy at the home is good, reflecting the reputation of the home in the local community. The staff at the home are also involved in the Care Ambassadors project which promote social care as a career in local schools and colleges; two staff members are named care ambassadors and have received appropriate training for this. What has improved since the last inspection? What they could do better: Uphill Court DS0000067101.V307157.R01.S.doc Version 5.2 Page 7 With respect to the physical environment, there must be a planned programme of redecoration and refurbishment of the home in order that continual improvement is maintained. Consideration should be given to the provision of a shower room. A 4-week menu must be planned which offers a choice of main course to residents. The continuity of staff working in the kitchen preparing residents meals must be re-established so that the quality and variety of meals is improved. Staff cooking meals must have suitable experience and qualifications to ensure the nutritional needs of the residents are adequately met. The continuity of care from the staff team must be continued to residents, and staffing levels must meet the issued staffing notice. The activity organiser should receive training so that they can work in such a way with residents so as to have a positive benefit on their daily lives. 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. Uphill Court DS0000067101.V307157.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 Uphill Court DS0000067101.V307157.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,5 Quality in this outcome group was good. Admission to the home only take place if the service is confident that staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. The home are then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the statement of purpose. EVIDENCE: The statement of purpose is available in the entrance hall and accessible to visitors and residents. The individual care files for residents indicated that a pre-admission assessment had been undertaken which ensured that the home was able to meet identified need. The residents and carers are given the brochure and service user guide to use to enable them to make an informed choice about the home and the services it offers. The pre-admission assessments were undertaken in either the resident’s own home or in a hospital setting, and were supported by information from the care manager and/or nursing staff. Uphill Court DS0000067101.V307157.R01.S.doc Version 5.2 Page 10 When potential residents are unable to visit the home prior to admission, the management invite relatives or carers to visit the home in order to see the facilities offered. Residents were able to confirm this verbally to the inspector. Uphill Court DS0000067101.V307157.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome group was good. Residents have individual health care plans which give a comprehensive overview of general health and acts as an indicator to changing health needs. The home works to an efficient medication policy supported by procedures and practice guidance. Induction training covers privacy and dignity. EVIDENCE: The case tracking through the case files indicated that the health, personal and social care needs was identified, and the home use various assessment tools e.g. manual handling risk assessments, dependency profiles. The home use the Waterlow assessment for the residents at high risk of developing pressure areas, and where a risk was indicated a subsequent plan of action to reduce/eliminate the risk was in place. Within the care files the inspector was able to see that care plans were regularly reviewed and changed as necessary. Trained staff and the carer giving the care complete the daily records. Some entries were objective and informative, whilst others were not, for example, all care given. This was discussed with the manager so that she can implement a recording system that is meaningful at the home and reflective of the care given to the Uphill Court DS0000067101.V307157.R01.S.doc Version 5.2 Page 12 residents. Some of records held may be repeating information i.e. carers record, trained nurse record, and this should be reviewed to reduce the burden of paperwork. However, it should be noted that if there is no written record then there is no proof of the care having been given. The physical appearance of the residents indicated that they were well dressed with clean coordinated clothing, well groomed and observed to be treated with respect. The home maintains a good standard of cleanliness and awareness of infection control; there are no residents at the home with MRSA. The home is meeting a wide range of health care needs and generally has quite dependent residents. The manager is experienced in assessing the needs of potential residents so that there is a sufficiency of resources in the home to meet their needs. At the time of the inspection none of the residents had any pressure ulcers, and the inspector observed that Allevyn dressings were used on some residents to protect vulnerable areas. The GP visits the home on a weekly basis and the manager liaises closely with the doctors surgery in order to meet changing health care needs. The manager also accesses other community health resources such as the mental health team. The inspector was made aware of two residents who have been prescribed medication for severe anxiety which has a sedatory affect. This was to reduce the distress and anxiety demonstrated by the residents in their behaviour. Although this is regrettable, the effect of the medication on both residents is being closely monitored. The inspector was able to meet both residents; one was able to respond appropriately to conversation, and the other resident was calm but not sleepy. Neither resident was showing any signs of ill being i.e. anxiety or distress, during the inspectors visit. The system for the recording and administration of medication was found to be in good order. New regulation on the disposal of medicines has come into effect and the home follow these procedures, using Pharmacy Plus as the licensed waste disposal company. It is good practice for CDs to be denatured prior to disposal, this includes injectables. They must be signed out of the CD register by a registered nurse and witnessed by a second nurse. Oramorph 10mg in 5mls would not be in this category and Fentanyl patches have instructions in the pack for safe disposal of used patches. Non CDs can go in a burn bin, however the home must have a record of all medications disposed of in this way, and it is important to have a second member of staff checking disposal. Uphill Court DS0000067101.V307157.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome group was adequate. The home tries to be flexible and attempts to produce a service, which is as individual as possible by using its staff and resources effectively. Residents are given the opportunity to take part in a variety of activities, however the service must attempt to tailor activities to the preferences and abilities of its residents. Food should not be cooked by care workers who are not qualified or experienced in food handling. Residents have limited choice of what they eat and the food is served plated. EVIDENCE: As part of the care planning process the recreational and social preferences for the residents at the home are identified. To stimulate the residents, there was an activity organiser whose role was to organise the recreational activities preferred by the residents, and which provide mental and physical stimulation for the residents. The activity organiser at the home during the session observed by the inspector, tried to meet to wide a need with too many residents and would benefit from training. Some residents stated that they would prefer to have more social contact and access the community. There were also books, games, and audiovisual equipment available to the residents. Uphill Court DS0000067101.V307157.R01.S.doc Version 5.2 Page 14 The staff are able on occasion to take residents out of the home to access the local amenities. During the inspection several of the residents had visitors. The visitors who spoke with the inspector were very positive about the standard of care at the home. The relatives present during the visit were very pleased that such a homely environment could be created within the care home, and likened the lounge area to a country pub. The inspector observed that the person doing the cooking was talking to residents about what was available to them from meals. When the inspector spoke to some residents they were able to inform her that there was staffing difficulties in the kitchen. The comments were that the food sometimes is not very good but they do their best. The residents confirmed that the variety and quality of food on offer was variable, but they did not like to raise this as they didnt like to be seen be seen to complain. The menu in use at home had no option for main meal, the planned meals were predominantly of cheaper variety i.e. sausages, beefburgers providing very little protein. The meal provided for a vegetarian, fish cake and sprouts, demonstrated that the staff cooking meals have little or no awareness of meeting the requirements of a balanced diet. This was discussed in depth with the manager who will produce a menu, which offers choices of main meal. The staffing situation in the kitchen must also be stabilised so that the quality of meals improves. The inspector would suggest that monitoring the quality of the meals served and particularly the amount of returned food may give an indication of the satisfaction of the residents who do not wish to voice complaints directly. Nutritional screening is part of the assessment for care and the inspector is confident that the manager and nursing staff team are fully aware of the need for a balanced diet. Uphill Court DS0000067101.V307157.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome group was good. The service has a complaints procedure that is clearly written and easy to understand. Residents understand how to make complaint but are reluctant to do so despite demonstrating that they have very good relationships with the manager. There are a low number of adult protection referrals because of a lack of incidents. EVIDENCE: Uphill Court has a rigorous complaints procedure; one complaint has been received since the last inspection, and has been resolved by the manager. Residents seem reluctant to complain, as they perceive that staff work hard and do their best for them. Most of the staff at home have undertaken training to enable them to recognise abusive practice, and the action taken to report any concerns. The manager will be organising further training through North Somerset Council. There have been no adult protection issues at the home. Uphill Court DS0000067101.V307157.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 26 Quality in this outcome group was adequate. The home requires financial investment to improve its physical condition and facilities for its residents and potential residents. The equipment in the home would benefit from being upgraded. The home is generally clean and tidy, and the staff team have hygiene equipment available to implement effective infection control. Residents can personalise their rooms and choose where they sit in the communal areas. EVIDENCE: Uphill Court is a listed building, which has been altered and had extensions to it so that it can function as a care home. The layout of the home does not lend itself to have easy access to all areas; some bedrooms are accessed via a stair lift, which limits their use for very dependent clients. The tour of the building indicated that a planned programme of repair and refurbishment should be implemented in order to maintain and improve the quality of the environment. Uphill Court DS0000067101.V307157.R01.S.doc Version 5.2 Page 17 The new owner is in the process of purchasing new bedroom furniture and soft furnishings. The garden area currently is inaccessible to residents as it is a steep slope, therefore the outside space is very limited. The home have several rooms with ensuite bathrooms, however, the majority of residents cannot get into the bath unaided. There are two accessible bathrooms available which residents’ access with support. One resident stated that they wished they were a shower room available or that their bath was turned into a shower instead of having to travel to have a bath. It would also benefit the home to replace some of the older hoists. One resident mentioned, and it was observed by the inspector, that the armchairs are in need of cleaning. Uphill Court DS0000067101.V307157.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome group was good. Residents have confidence in the staff to care for them. The manager ensures that the home is staffed effectively with particular attention given to busy times of the day and the changing needs of the residents. The service has a good recruitment procedure that clearly recognises the importance of effective recruitment in the delivery of good quality services and for the protection of residents. The benefit of a settled staff team who can deliver continuity of service to residents will be compromised if staff face uncertainty in the hours they work. EVIDENCE: The issued staffing notice for the home is adhered to, it allows for a reduction in care staff in relation to the number of residents at the home. Due to the fall in resident numbers staff hours have been reduced. This has caused disruption amongst the care staff, turnover of staff at the has been home low, however the manager has recently received resignations from three staff members. To ensure that the continuity of care for residents is provided, the uncertainty amongst the staff team should be resolved. At the time of the inspection there were 19 residents at the home, 10 of which were high dependency, six of medium dependency and four of low dependency. Using the Department of Health Residential Care Forum guidance on staffing the total duty hours should be 602 per week. This would include all care staff, trained nurses, manager and activities organisers. Uphill Court DS0000067101.V307157.R01.S.doc Version 5.2 Page 19 Use of agency staff is minimal. All of the residents have an allocated key worker. There is a robust policy and procedure for recruitment of staff to the home, but the manager must ensure that it is properly implemented especially in respect of induction of new staff to Uphill Court. The trained nurses at the home are supported by a team of care assistants, 50 of whom have NVQ 2 or above. The manager ensures there is a training planned for staff to attend, some of the in-house training sessions include manual handling updates. The home also access the training sessions available from the North Somerset PCT and Weston College, which include distance learning courses for aspects of care such as Nutritional Health. Uphill Court DS0000067101.V307157.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome group was adequate. The manager has the required qualifications and experience and is competent to run the home. She works to continuously improve services and provides an increase quality of life for residents. Due to the recent change in ownership, the lines of accountability and responsibility at the home are not clearly defined. The business planning for the home should be based on realistic occupancy and take into consideration the current market locally. EVIDENCE: The manager, Jana Harris, has continued to implement good practice at home, in respect of the implementation of the care planning for residents, staff Uphill Court DS0000067101.V307157.R01.S.doc Version 5.2 Page 21 training and recruitment, and providing a safe and stimulating environment for the residents. The manager has undertaken NVQ 4, and is a tutor for adaptation students. In addition to this she provides some of the in-house statutory training for staff. The manager has also demonstrated leadership skills in the administration of the home, staff management i.e. regular staff meetings and has the confidence of the staff team. The new owner for the home, visits on a weekly basis and relies on the manager for the day-to-day running of the home. The relationship is relatively new and it is advisable to establish clear lines of accountability especially in respect of staff budgeting in relation to the dependency of the residents. The staff were not widely consulted by the inspector on this visit due to the uncertainty caused by the new ownership. However the inspector observed that the manager was approachable and listened to staff. There are regular staff meetings, and the staff are involved in daily handover of information directly relating to the care of the residents. There was documentary evidence of formal supervision and appraisal of staff; however the standard of six sessions per year has not been met and the inspector discussed with the manager and deputy manager the most meaningful way in which supervision can be introduced to the home. It was agreed that supervision sessions could be a mixture of formal meetings, and informal observation of practice. However for both of these types of supervision a record must be kept and feedback must be given from the supervisor to the supervisee. The manager will monitor the success of this system. The quality assurance currently in is a yearly visitor/relative questionnaire that has been distributed and the results collated. The residents were consulted on a one-to-one basis by staff. The result of the questionnaire has been collated, the outcomes communicated to process and residents, and this has influenced the day-to-day running of the home. The new owners have provided a business plan for the home to the Commission. The financial viability of the home will be dependent on high occupancy levels and the reduction of staffing costs (through reduced agency use). The plan may not be achievable in the current market as there are a high number of vacancies locally in both personal care homes and nursing homes (approximately 130). There is also competition locally for experienced care staff and trained nurses, many homes pay above the minimum wage, and if there is continued uncertainty about the amount of hours available at the home, then staff will leave. These factors combined will affect business plan projections. Both of the manager and new owners have been proactive in seeking referrals to the home by placing local advertisements of vacancies. The reputation of Uphill Court DS0000067101.V307157.R01.S.doc Version 5.2 Page 22 the home at present is good and the home does not rely on verbal recommendation. Evidence for the insurance cover for the business was available and on the wall. The fire safety procedures at the home are implemented as per the recommendations. There was evidence of regular maintenance of the electrical system, alarm system, and portable electrical appliance testing Uphill Court DS0000067101.V307157.R01.S.doc Version 5.2 Page 23 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 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 3 3 X 3 X 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 2 3 4 3 X 2 X 3 Uphill Court DS0000067101.V307157.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP12 Regulation 16,18 Requirement Staff must be trained appropriate to their role i.e. activity staff and provide leisure activity appropriate to the client group. A four week menu offering choice of main meal must be provided for residents so that they can make an informed choice about their meals. Persons responsible for cooking meals must be trained to do so. There are clear lines of accountability between the manager and owner of the home. The staff must receive regular supervision of their work practises. Outdoor space should be made accessible to the residents. A programme of maintenance and renewal of the fabric of the building is implemented. Timescale for action 16/11/06 2 OP15 16,18 16/11/06 3 4 OP30 OP15 OP31 16,18 16 16/08/06 16/11/06 5 6 7 OP36 OP20 OP19 18 23 23 16/10/06 16/04/07 16/09/06 Uphill Court DS0000067101.V307157.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Uphill Court DS0000067101.V307157.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Taunton Office Ground Floor Riverside Chambers Castle Street, Tangier Taunton Somerset TA1 4AL National Enquiry Line: 0845 015 0120 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. 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