Care Home: Abbeygate

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What the care home does well Abbeygate continues to provide a homely, caring and supportive environment. Staff are dedicated to meeting the needs of people living in the home in a personal, Person Centred way. The opinions of people in the home are valued, encouraging independence and taking into account the need to respect dignity and privacy. Comments received about Abbeygate were very positive. People told us in their surveys that they were happy with the care provided at Abbeygate one relative said, `We are delighted with Abbeygate in all respects and feel a special mention is merited for the excellent homely atmosphere and attitude of the staff at all levels of involvement.` Whilst resident comments said, `This is a very happy home we are well cared for.` `This a very happy home with a good atmosphere` and `it is a wonderful home from home the staff are so cheerful and caring.`We also received surveys from staff working in the home, they said Abbeygate provides a home where, `Residents are looked after well, whilst promoting choice by listening to people as individuals.` Staff also indicated that they had good opportunities for training and were encouraged to complete the NVQ 2 In Health and Social Care. This has resulted in the home having 60% of their staff qualified to NVQ level 2 or 3. What has improved since the last inspection? Since the last inspection the manager has met all the requirements made. A clear risk assessment has been completed for all areas of the home and for working practices in the home. A COSSH record is available for staff to consult and staff know where it is kept. A service record is kept for showing that the hoists used in the home are checked and serviced every six months. Since the last inspection the group of homes has adopted person centred care planning which was developed to meet the assessed needs of people living in the three homes. The care plans look at individual needs and wishes. This shows an understanding of the right people have to continue to take control over their lives when they move into a care home setting. The manager has also followed the good practice recommendations made. A record is kept of all concerns complaints and compliments made. They include how the manager responded and the outcome. The whistle blowing policy directs people to the Local Authority and staff were aware of the contact details. The new person centred care plans include a record of activities attended by people living in the home. What the care home could do better: No requirements were made as a result of this inspection; we made one good practice recommendation. We noticed that handwritten entries on the medication charts for people in the home for short-term respite had not been signed and witnessed. We have recommended that all handwritten entries on the medication chart should be signed and witnessed by another member of staff to prevent mistakes being written down and putting residents at risk of receiving the wrong medication. CARE HOMES FOR OLDER PEOPLE Abbeygate 71 Beach Road Weston Super Mare North Somerset BS23 4BG Lead Inspector Juanita Glass Unannounced Inspection 10:30 23 and 25th July 2008 rd 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 DS0000008027.V366912.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. DS0000008027.V366912.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeygate Address 71 Beach Road Weston Super Mare North Somerset BS23 4BG 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) 01934 621166 01934 419244 general-manager@abbeycarehomes.org.uk WSM Free Church Housing Association Mrs Joan Patricia Duffy Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places DS0000008027.V366912.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2006 Brief Description of the Service: Weston-super-Mare Free Church Housing Association owns Abbeygate. The home is registered with The Commission for Social Care Inspection to provide Personal Care only for 21 elderly residents. They do not provide nursing care, however if a resident requires short term nursing input they are well supported by the Local Community Nursing Team. The homes care is based on a Christian philosophy however they are able to accommodate people who may have another religious belief or no wish to follow a belief. Abbeygate overlooks the sea front at Weston-super-Mare. The property is a large Victorian house with a long conservatory leading to an annex at the rear. There is a large lounge, leading to a well-stocked library. This is used for daily prayers and Sunday church services. A television lounge and dining room are also located on the ground floor. There is a well-maintained garden to the front and a sheltered courtyard outside the conservatory. A local park is situated behind the home. Buses pass the home; otherwise a car would be necessary to access the town centre. All bedrooms are for single occupation and have en-suite facilities. The registered manager is Mrs Joan Duffy she is an experienced manager who has completed the Registered Managers Award and is supported by two deputy managers and relief deputy managers. A Volunteer House Visitor, who visits regularly and talks to people about the care provided by the home, also supports people living in the home. Current fees. £400 per week £425 per week for respite care. DS0000008027.V366912.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection took place over two days in the presence of the manager Mrs Joan Duffy a total of 7 hours were spent in the home. Evidence to support the findings of this inspection was obtained through written surveys from people living in the home and their relatives. Reponses to our written survey were received from 6 people living in the home and 2 relatives. An Annual Quality Assurance Assessment (AQAA) was completed by the home manager and forwarded to the Commission for Social Care Inspection (CSCI). We The Commission also carried out a review of documentation in the home. This included documents in peoples care plans, staff personnel records and records maintained for the day-to-day running of the home. Whilst in Abbeygate we discussed the care provided with 8 people living there on a one to one basis and as a group. We also spoke to the Volunteer House Visitor who was present on the first day of our visit. We observed staff working practices and spoke to 4 staff members over the two days. What the service does well: Abbeygate continues to provide a homely, caring and supportive environment. Staff are dedicated to meeting the needs of people living in the home in a personal, Person Centred way. The opinions of people in the home are valued, encouraging independence and taking into account the need to respect dignity and privacy. Comments received about Abbeygate were very positive. People told us in their surveys that they were happy with the care provided at Abbeygate one relative said, ‘We are delighted with Abbeygate in all respects and feel a special mention is merited for the excellent homely atmosphere and attitude of the staff at all levels of involvement.’ Whilst resident comments said, ‘This is a very happy home we are well cared for.’ ‘This a very happy home with a good atmosphere’ and ‘it is a wonderful home from home the staff are so cheerful and caring.’ DS0000008027.V366912.R01.S.doc Version 5.2 Page 6 We also received surveys from staff working in the home, they said Abbeygate provides a home where, ‘Residents are looked after well, whilst promoting choice by listening to people as individuals.’ Staff also indicated that they had good opportunities for training and were encouraged to complete the NVQ 2 In Health and Social Care. This has resulted in the home having 60 of their staff qualified to NVQ level 2 or 3. 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. DS0000008027.V366912.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 DS0000008027.V366912.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5. 6 does not apply Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents benefit from adequate written information, a chance to visit the home and a full assessment of their needs. This means they can make an informed decision before moving in and their needs are fully met. EVIDENCE: We the Commission looked at a copy of the homes Statement of Purpose and Service user guide. This was readily available in the home and provided immediately. We saw that it was well written and contained all the information a person would need to tell them about what care the home can and cannot provide. It also states clearly the fees and what they pay for with a list of extra charges clearly mentioned. We saw in a resident’s room a copy of the service user guide, people spoken to did not comment on the guide. Although Abbeygate is a Christian run home the documentation we looked at showed clearly that they could also accommodate people with other religious beliefs or people with no chosen belief. DS0000008027.V366912.R01.S.doc Version 5.2 Page 9 We spoke to the manager about how they would assess a person who wished to move into the home. She said they would visit the person either at their home or in hospital. They would talk to them, a relative or advocate and staff at the hospital or a social worker. They would also look at existing care plans for the person. We then looked at the records held in the home for people who had not lived there very long. They all had completed assessments and community or hospital care plans. We spoke to the people living in the home, but they did not mention how the experience of moving into Abbeygate had been for them. People wanting to move into Abbeygate can visit and spend some time to meet other people living there and staff who will be looking after them. This is often done by a relative or advocate on their behalf. If the manager and staff feel they can meet the needs of the person they will offer a trial period when both the person moving in and staff can decide whether the home is really the best placement for them. DS0000008027.V366912.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from personal and specialist healthcare support that is provided in a person centred way respecting their privacy and dignity. They benefit from and are protected by the homes policies and procedures for the administration of medication, however unsigned handwritten entries do not show that staff are fully aware of the policies and procedures. EVIDENCE: Since the last inspection a person centred approach to care has been introduced to all three homes owned by Weston-super-Mare Free Church Association. We looked at the care plans for four people they all showed that the staff at Abbeygate understand the way to record the personal way a resident likes to be cared for. All the care plans seen reflected this approach with clear guidelines for staff about peoples likes and dislikes and the way in which they preferred to receive their care. Staff had written care plans that reflected the person’s personal preferences and the way they wished to be DS0000008027.V366912.R01.S.doc Version 5.2 Page 11 cared for. Staff spoken to said they knew each individual, their preferences and when they preferred to be helped or left alone. We observed staff chatting and laughing with residents in an easy and relaxed way. People we spoke to said they felt staff ‘knew how they preferred to be looked after.’ One person said that ‘although it was not their own home it was the next best thing.’ Another person said ‘they always know when to be there or when to back away they are all very nice people.’ All the care plans included appropriate risk assessments and showed signs of regular review. Care plan reviews also reflect the changes in people’s lives, which are also agreed with the resident or their relative People living in the home have access to health care specialists and care plans showed that the district nurse could be consulted when the home felt they needed some expert advise. Residents were helped to attend out patient appointments, the dentist and the chiropodist. Regular reviews are carried out with the GP looking at specific health needs and medication. The home has very clear policies and procedures for the receipt storage and administration of medication and staff receive training before they can give medication to people. Some residents look after their own medication following a full risk assessment of their understanding. We looked at the records kept by the home for medication given to people we found that they were up to date and showed clearly when staff had given them to people. We saw that hand written medicine charts for people staying in the home on respite care were not signed or witnessed by another person. This puts people at risk of receiving either the wrong medication or the wrong dose. We have recommended that two signatures need to be on handwritten medicine charts when staff write up the charts. DS0000008027.V366912.R01.S.doc Version 5.2 Page 12 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from the development of meaningful activities which recognises their diverse needs, likes and dislikes enabling them to maintain some control over their lifestyle. They benefit from continued contact with family, friends and the community. A well-balanced menu means people benefit from a healthy and nutritional diet. EVIDENCE: We asked people about the activities that were provided in the home. Most of the people spoken to said they knew there were activities provided and could join in if they wished. One person said they had been asked at a residents meeting about what activities they would like and staff had listened to their suggestions. We saw the minutes of the residents meeting and people had said what they would prefer to do. One resident said they preferred to remain in their room and read books, do crosswords and watch programmes on the TV. They also said they knew they could join in with a group activity if they wanted to. Staff said it was sometimes difficult to get the current group of residents to join in an organised DS0000008027.V366912.R01.S.doc Version 5.2 Page 13 event, as they liked to do their own thing. People living in the home had indicated to staff that they would prefer to take part in a planned activity later in the afternoon such as between 4pm and 5pm leaving them free to do their own thing through the day. Whilst we were in the home one person went out for a ride on their electric chair to the park whilst another went out with a relative. People were seen to come and go as they wished. Daily prayers are held each morning these are often organised by a resident. The home also encourages residents to attend their preferred place of worship, when they wish. People spoken to confirmed that their relatives and friends are made welcome in the home. During the inspection relatives were seen to come and go throughout the day. They commented on the friendly and welcoming approach of staff who would assist them to find the person they were visiting and make the visit a pleasant one. The main ethos in the home is that people living there are given the chance to take control of their daily routine wherever this is practicable; people are given a degree of choice in most aspects of their lives. Residents spoken to said that they could exercise choice and control over their own lives and felt that the home was run for their benefit. Staff spoken to were very conscious of helping people living in the home to continue to make personal choices. Residents are asked on a daily basis about their meal preference. This is then conveyed to the cook. If a person does not want either choice another option can be offered. There is a good range of hot and cold options offered at each meal. The menus continue to contain a variety of well-balanced meals that reflect the preferences of the people living in the home. People spoken to and the written surveys indicated that the meals were of a good standard. DS0000008027.V366912.R01.S.doc Version 5.2 Page 14 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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from and are protected by the complaints and safeguarding procedures in the home. Staff are fully aware of the procedures to follow to protect people from abuse. EVIDENCE: Abbeygate has a very clear complaints policy and procedure, which is easy to read. It shows a clear timeline and action to be taken if some one wishes to raise a concern or complaint. A copy is clearly displayed in the home. We saw that people living in the home had signed that they had seen and read or had the complaints policy explained to them. The policy and procedure also directs the complainant to the CSCI. The manager keeps a full record of all concerns, complaints and compliments they receive. People spoken to said that they knew how to raise a concern, they also said they could bring anything to the attention of staff and not feel awkward about it. Residents also benefit from a house visitor who can act as an advocate if a resident felt they could not talk to a member of staff and they can attend the resident meetings. DS0000008027.V366912.R01.S.doc Version 5.2 Page 15 We saw a copy of the North Somerset policy and procedure for Safeguarding Adults under No Secrets, which is available for all staff to read. Staff spoken to said they knew who to inform if they suspected abuse and they all knew about the homes whistle-blowing policy. Staff records showed that they had all received appropriate training in Safeguarding Adults. DS0000008027.V366912.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from a comfortable, well-equipped and homely environment, which is well maintained and decorated with access to well maintained garden areas and local parks. People are protected by staff awareness of appropriate infection control guidelines. EVIDENCE: We carried out a tour of the home; we looked in people’s rooms with their consent. The home is well furnished in such a way that people living there can sit in small groups. The furnishings and lighting are domestic in style whilst providing adequate light to read by. The furniture and fittings are of good standard and communal areas are pleasantly decorated. The facilities include a DS0000008027.V366912.R01.S.doc Version 5.2 Page 17 separate dining room, two lounge areas and gardens. One of the larger lounge areas is at the front of the property. This lounge has a wall divide providing a small quiet library/reading area. The other lounge area overlooks the inner courtyard. The home provides seating in a conservatory area, which again overlooks two inner courtyard gardens. A programme of re-decoration is being followed as and when rooms become available. People spoken to said that they liked their rooms and had bought in their own furniture which made them feel more at home. We sat in one room talking to a resident who was surrounded by personal possessions and ornaments bought in from their home. They said they had a nice bright room, which was large enough to be divided with a settee making it feel less like a bedroom. The resident said that the staff that did the cleaning was very thorough and everything was dust free and clean. People living in the home also have access to outside areas. The home shows a good standard of housekeeping and no offensive odours were apparent. The manager and staff showed a clear awareness of infection control policy and guidelines. Protective clothing was being used when appropriate and the manager can obtain guidance from outside agencies if required. DS0000008027.V366912.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from and are protected by the staffing levels and skill mix of staff in the home. The homes recruitment procedures and staff training further protect them from the possibility of abuse. EVIDENCE: We looked at the personnel files held by the home for some of their staff. We looked at the employment records for two recently employed members of staff. We also looked at the staffing rota and the training records for people working in the home. The staffing rota showed that there is always enough staff in the home with the right skill mix to support the diverse needs of the people living there. They also showed that staffing is flexible so extra staff could be bought in to cover extra busy times such as activities or trips out. People spoken to said there were always enough staff in the home and they never had to wait long if they rang their bell for help. The manager confirmed that staff are encouraged to attend the NVQ In Health and Social Care training. This has resulted in the home having 60 of their DS0000008027.V366912.R01.S.doc Version 5.2 Page 19 staff qualified in an NVQ 2 or 3 and other staff working towards the qualification. Staff surveys indicated that they were well supported with training. Staff personnel records showed that all mandatory training had been attended and dates for further updates were advertised in the office. Staff had also attended training that was considered relative to their role in the home and the diverse needs of people living there. Staff said they felt well supported by the manager in attending any training they were interested in that would also benefit the home. Abbeygate has strict policies and procedures for the recruitment of new staff. The personnel files for two people who had recently been employed showed that the manager follows these guidelines as all the relevant checks such as references and a CRB (Criminal Bureau Records) check had been completed before the person started work. This protects people living in the home from possible harm or abuse. DS0000008027.V366912.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from living in a well run home with an appropriately qualified manager and supervised staff. They are protected from financial abuse through safe and stringent policies for managing resident’s money. Both people working and living in the home are protected by robust health and safety procedures. EVIDENCE: The registered manager is Mrs Joan Duffy and two deputy managers and relief deputy managers also support her. She is an experienced manager who has completed the Registered Managers Award and also an update in management skills. People spoken to said that they felt able to approach the manager and DS0000008027.V366912.R01.S.doc Version 5.2 Page 21 deputies if they wanted to raise issues. The house visitor also supports the service users as an intermediary. Residents meetings continue to be held and the minutes we looked at showed that residents attend and discuss their views on the way the home is run and the facilities provided. An annual survey of residents’ views is carried out; when these are returned and put together a meeting is held to discuss any issues raised. The Annual Quality Assurance Assessment (AQAA) returned to the CSCI was clear about the homes continued commitment to maintaining improvement and providing an environment that recognises the diverse needs of the people in their care. The manager confirmed that the home currently does not directly handle residents’ financial affairs. People either manage their own money or have a relative or power of attorney to act on their behalf. Staff personnel files showed that regular supervision is planned and carried out. Staff discuss with the manager their progress with training and their working practices. Any training and development needs are identified and plans put in place. Staff surveys indicated that they felt well supported and received adequate supervision. We looked at records relating to the servicing of equipment used in the home. The manager now has clear evidence to show that the hoist used in the home is checked and serviced every 6 months. All the records were up to date and available for inspection, these included the COSHH records, which are the guidelines for staff to follow if they spill, drink or are splashed by chemicals used in the home. The implementation of health and safety within the home was satisfactory. All residents have personal risk assessments. Generic risk assessments are in place and reviewed regularly including hot water checks. A review of the firelog showed all tests, training and drills were being carried out to the Avon and Somerset Fire Brigade guidelines. DS0000008027.V366912.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 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 3 X 3 X 3 3 X 3 DS0000008027.V366912.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 The manager needs to ensure that all handwritten entries on the medication chart are signed and witnessed by another member of staff. This is to prevent mistakes being written down and putting residents at risk of receiving the wrong medication. DS0000008027.V366912.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 DS0000008027.V366912.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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