Care Home: Bishops Waltham House

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What the care home does well The home provides care in a generally well-maintained, pleasant and welcoming environment. Residents are supported by a team of staff who are well-managed, supported, motivated, well-trained and qualified, and who work in a manner that recognises resident`s need for personal privacy and dignity. What has improved since the last inspection? All of the previous requirements relating to the assessment and care planning process, staffing level, recruitment records and supervision have all been complied with. Also following a period when a temporary manager was responsible for the home, a qualified and experienced permanent manager is now in post and is in the process of applying for registration What the care home could do better: Following this inspection no requirements were made and there were no areas of concern. However to ensure that all residents are able to understand the daily menu, this should be produced in a format or formats that all residents can understand. Also the quality monitoring process would be improved if the views of relatives and social and health care professionals were sought CARE HOMES FOR OLDER PEOPLE Bishops Waltham House Bishops Waltham House Free Street Bishops Waltham Southampton Hampshire SO32 1EE Lead Inspector Peter J McNeillie Unannounced Inspection 09:00 28th April 2008 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 Bishops Waltham House DS0000038911.V363536.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. Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bishops Waltham House Address Bishops Waltham House Free Street Bishops Waltham Southampton Hampshire SO32 1EE 01489 892004 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) lindsey.putt@hants.gov.uk Hampshire County Council Vacant Care Home 52 Category(ies) of Dementia - over 65 years of age (52), Old age, registration, with number not falling within any other category (52) of places Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th June 2007 Brief Description of the Service: Bishops Waltham House is a care home owned and managed by Hampshire County Council registered to provide support, care and accommodation for up to fifty-two older persons some of whom may have dementia. The purpose built home which is set in extensive well maintained and safe grounds was built in the 1970s. It is located on the outskirts of the village of Bishops Waltham close to local amenities, the M27 motorway and the cities of Southampton, Portsmouth and Winchester and a large retail park. Accommodation is provided on three floors, which are served by two passenger lifts to the upper floors, parts of which have recently undergone an upgrade and refurbishment. The next, very extensive stage of a major refurbishment which will result in a reduction in the number of resident to eighteen persons whilst work is being carried out, was due to commence within weeks of our visit. The home fees were dependent on individual residents personal financial circumstances and ranged from the state pension less an individual’s permitted weekly personal allowance to a maximum of £413. Bishops Waltham House DS0000038911.V363536.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 report was written after taking into consideration a number of sources of information and evidence including a site visit to the premises, previous reports, responses by the registered provider to the previous report, sampling residents records and staff training and recruitment records. We talked with residents, staff and management and received a response by the manager to a pre inspection Annual Quality Assurance Assessment. (AQAA). The results of in house satisfaction questionnaires completed by residents and resident’s representatives were also viewed. During this inspection which took place on 28/04/08 between the hours of 9.00 am and 2.30pm we were assisted by the manager and other members of care and support staff. At this inspection, the standards for older persons and any previous requirements were inspected. As a result of this visit we found all previous requirements had been complied with and are commented on in the main body of this report. The results and findings contained in this report will determine the frequency and type of future inspections. What the service does well: What has improved since the last inspection? All of the previous requirements relating to the assessment and care planning process, staffing level, recruitment records and supervision have all been complied with. Also following a period when a temporary manager was responsible for the home, a qualified and experienced permanent manager is now in post and is in the process of applying for registration Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 6 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. Bishops Waltham House DS0000038911.V363536.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 Bishops Waltham House DS0000038911.V363536.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): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a system of assessing and identifying resident’s needs which ensures residents safety and that their assessed needs can be met in compliance with a previous requirement. Intermediate care is not provided so this standard does not apply. EVIDENCE: Following the last inspection a requirement was made that: “Pre admission assessments need to be completed for all residents including those admitted for respite, to ensure the home can meet their care needs”. In response to this requirement we received a written response on 17/07/07 from a senior external manager stating “A system is now in place to ensure pre Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 9 admission assessments are completed by the home prior to a resident coming to stay”. Due to the refurbishment that has and is currently taking place the home has not admitted any permanent residents since the last inspection and only admitted residents for respite who had used the service previously. The home had written policies and procedures regarding the admission of new residents to the home. These stressed the importance of accurately assessing any risks, as well as the help and support required by potential residents. These assessments were carried out before residents moved into the home by the manager or another member of the management team. This procedure would normally take place where the potential resident was residing or during a day visit to the home or a combination of both of these situations. Whilst talking to current residents we established that they or their representatives had been involved in the initial assessment process, and the records viewed confirmed this. As part of the admission process management also liaise with external health and social care professionals regarding any care needs, risks, equipment and aids, that need to be taken into consideration when developing a plan of care. In view of the evidence seen we are satisfied the previous requirement has been complied with and a procedure is in place to ensure continued compliance. Bishops Waltham House DS0000038911.V363536.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. The home has a well-developed system of planning and reviewing care, which reflects residents, wishes, and aspirations and ensures resident’s needs are met. A risk management policy involves residents and resident’s representatives or relatives in decisions that affect them in compliance with a previous requirement. EVIDENCE: Following the last inspection a requirement was made that:” Care plans need to be completed and reviewed, if possible in consultation with the resident to ensure the plans record the residents current needs and wishes.” In response to this requirement we were informed on 18/07/07 that:” Care plans are currently being reviewed and updated with residents and assistant unit managers and we will ensure this is completed by 31.07/07.” Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 11 To check compliance we viewed four residents care plans selected at random. All of the detailed care plans, which were reviewed at least monthly, were based on pre admission assessments to which standards 1-6 of this report refer. These reflected resident’s needs, risks, choices, wishes and aspirations. Some residents verbally confirmed they were consulted about and participated in the production of the plan, others could not remember. Records seen also confirmed consultation had taken place. All of the residents spoken with confirmed they were very satisfied with the care and support they received. They advised us they were contented, liked the staff and management and were treated with respect; their privacy respected and were kept fully informed about the refurbishment plans and how it might affect them. Residents responses to our questions about how they were cared for and liked living in the home were all very positive and included comments such as “ A1 ” “I am very happy here”,” Well satisfied and content”,” Care is very good” “The staff are lovely and very kind”.” You wont find anything wrong here”. ”The best”. ”Food is good.” Resident also confirmed that they were addressed in a way that they had agreed, and that staff always knock on their bedroom door and wait before entering, a practice we observed during this visit. In the light of the above information we consider the previous requirement had been complied with. Residents who were spoken with also confirmed they were able to see the doctor of their choice or any other health and social care professional when they needed to. The records viewed indicated that apart from doctors, district nurses, physiotherapists, occupational therapists, other specialists had been consulted when required. Records were kept of appointments with GPs, dentist, optician, chiropodist and any other external health and social care professional and included details of any advice and treatment given. To ensure equality and diversity are promoted within the service the home, they informed us in their AQAA that: ”To ensure compliance with a corporate Hampshire County Council policies on equality which was available on the internet “We apply these policies for both residents and staff in this home, including in our recruitment programme, we do not enquire about the specific gender identity and sexual orientation of the residents and staff, and may not have this information unless they choose to disclose it, or it becomes evident as part of their care planning. The Corporate Equalities Officer, informed by legislation, research and stakeholder consultation, regularly updates this Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 12 policy. We will undertake a Race & Equality Impact assessment, as a systematic way of finding out whether an existing or proposed policy or strategy of our service will affect different groups differently. In this way we are able to challenge and eradicate any residual institutional discrimination” in this home, and ensure that policies, services and strategies do not, and will not, impact in a discriminatory way. (link http:/intranet.hants.gov.uk/equality/impact.htm) We ensure that specific cultural and religious needs are incorporated in our care planning and each resident has a thorough, individualised care plan prepared on admission and developed in line with changing needs and wishes. Residential, Nursing and Day Care Practice Manual V.2 http:/intranet.hants.gov.uk/adult-services/procedures-polices.htm We actively encourage the involvement of carers, family, friends and community groups in the daily life of the residents. We are able to provide specific issue training for our staff where necessary, and when possible we prefer to undertake this in liaison with the community.” Medication records confirmed that all prescribed medications, which are securely stored, are dispensed by a pharmacist into a blister pack system.. These are administered in accordance with a medication policy and procedure by staff who had all received training on the handling of medications. All staff confirmed they were aware of and had read the medication procedure. The record of medications administered to residents, and any unwanted supplies which were disposed of, were complete and accurate. A procedure was in place to enable residents who wish to assume responsibility for their own medication. At the time of the inspection no resident was managing his or her own medication in accordance with a risk assessment. Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. The social activities, maitenance of family contacts, and the provision of varied and nutritious meals were well managed and reflected residents interests and choices. EVIDENCE: A selection of recreational activities was available to residents, including art, craft, reminisance, quizzes, gardening, music, exercise, fish and chip suppers, bar b q’s, cooking, trips out, external entertainers, as well as special celebrations for birthdays, Easter and Christmas. Residents confirmed how important the activities were and how much they enjoyed them. All confirmed that participation was up to the individual; no one was forced to join in. Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 14 The home has regular visits from local Church of England clergy who conduct services/communion in the home. The needs of members from any other Christian denominations or other faiths can be catered for. Residents confirmed they were fully consulted and were able to exercise choice in all aspects of their lives for such as when to get up and go to bed, mealtimes and where meals are taken, visiting times and the right to receive and converse with visitors in private. Residents also confirmed visitors were welcome at any time and that they were able to maintain links with the local community. The quality, quantity, presentation and choice of food served came in for particular praise from the residents. A written daily menu based on resident’s likes and dislikes was displayed. We highlighted the need to ensure that the menu was displayed in format that all residents would understand. This is of prime importance for persons with dementia who may find the addition of pictures would be beneficial to understanding the daily menu and when making choices. The manager gave a verbal undertaking he would look into the way menus were displayed in future. Vegetarian options are always available. Persons on special diets for religious or medical reasons can also be catered for, following individual written nutritional assessments which are carried out for all residents. We observed residents taking their mid day meal. This was conducted in a relaxed unhurried manner with staff available to give any resident assistance should they require it. We can confirm the quality, choice and presentation of the meal observed by us during our visit was good. Tea and coffee making facilities were available to all residents and visitors at all times. Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure was satisfactory with evidence that residents feel their views will be acted upon in compliance with a previous requirement. The home has clear policies and procedures in place which ensures residents are protected from abuse. EVIDENCE: The complaints procedure, which is also included in the service users guide, included information on how to contact The Commission for Social Care Inspection (CSCI), was seen, as was the record of complaints. CSCI have received not received any information about complaints made to the home since the last inspection. All members of staff spoken with of stated they felt confident in discussing any concerns or complaints with management either in house, or external on behalf of any resident. The home’s corporate adult protection policy and procedure produced by Hampshire County Council is based on National Guidelines and the document No Secrets, and is designed to safeguard residents from abuse. Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 16 Management and staff who were spoken with confirmed they had all received training in recognising various types of abuse, and this was confirmed by records viewed. All were able to demonstrate they knew the procedure to follow should they witness or suspect the abuse of any resident. Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 17 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A safe, well maintained, clean and suitably furnished home is provided for residents which meets their needs. EVIDENCE: All areas of the home were clean and free from unpleasant odours and obvious hazards. Furniture was comfortable, homely and met the needs of residents who confirmed the home is always clean and smells fresh. For the past few years a major refurbishment has taken place in the home. This has resulted in a non admissions policy and the numbers of residents Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 18 being reduced, from a maximum of fifty-two residents to thirty-six, whilst work was carried out. Since the last inspection the improvements have included upgrading the fire safety facilities with the installation of two lifts that can be used in the event of fire, new lighting and an improved fire detection system as well as improvements to bedrooms and bathing facilities. Following a County wide review of resources and services, the home is due to have further major financial resources spent on in to upgrade the remaining parts of the building to meet present day standards and expectations. The work, which will last over a thirty-week period, is due to commence in May 2008. During this period all admissions will be suspended the number of residents being accommodated reduced to eighteen. All of the residents spoken with accepted the need for improvement despite the inconvenience it may cause them. We were informed the remaining residents and their families will be kept fully informed of the changes as they occur, and that any plans agreed will take into account the special environmental needs of persons with dementia. Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 19 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. Resident’s needs are met by sufficient numbers of well trained and supported staff who are recruited and selected using a procedure designed to protect all residents in compliance with a previous requirement. EVIDENCE: Following the last inspection the following requirements were made: 1) “Staffing levels should be reviewed to ensure sufficient staff are on duty at busy times of the day.” 2) “Staff recruitment records including references, POVA and CRB checks should be available to inspectors for them to confirm all the necessary documentation has been obtained”. We received a response to these requirements to both of these requirements in writing on 18/07/07 when we were informed that: 1) ”Staffing levels have already been improved to reflect the needs of residents at core times of the day. The registered manager is keeping this requirement regularly reviewed.” 2) “Staff recruitment records have been updated to ensure they comply with the standards.” Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 20 In checking compliance with the fist requirement we were informed by the manager that the planned daily staffing levels for the home each day is: 7.30am –3pm: three carers and a duty manager plus a cook, kitchen assistant, cleaner, laundry assistant and an administrator. 2pm –10 pm three carers plus a duty manager. 10pm to 7.30am three waking night staff plus an on call duty manager. The daily staff rota was viewed, and confirmed these staffing levels. At the time of our visit, in our view the number of management, care and support staff met residents needs, a view supported by the manager, staff and residents who informed us there were always enough staff on duty and they rarely had to wait for attention. To ensure compliance with the second requirement we viewed four staff recruitment and training files. All files which were seen of included evidence that staff are employed in accordance with a robust recruitment, equal opportunities and selection procedure, which is designed to protect residents. This involves the completion of an application form, the signing of a rehabilitation of offender’s declaration, an interview, and satisfactory Criminal Record Bureau (CRB) disclosure, Protection of Vulnerable Adults (POVA) and reference checks. Following their appointment, records seen confirmed that all staff are subject to an in house and corporate induction and compulsory training programme that include first aid, handling medication, moving and handling, POVA, infection control and dementia. All staff are expected to undertake a National Vocational Qualification (N .V. Q.) course. Currently 73 of staff has been trained to at least NVQ level two, of these three have obtained NVQ level three and a further 7.7 are on a level two course. This is a very creditable result for which the home’s management are to be congratulated. In view of the information received and the evidence viewed we are satisfied that both of the previous requirements have been complied with. Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 21 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): 31,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home ensures the health, safety and welfare of residents and staff are promoted, and the home is run in the best interests of the residents, whose views about living in the home are formally sought. All previous requirements have been complied with. EVIDENCE: For some time prior to the previous inspection the homes registered manager had been absent due to sickness. Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 22 In our report we commented that: “The lack of stable management of the home has been a factor in records not being kept up to date and the lack of staff supervision.” In response to the above comment and a requirement made following our visit we received on the 18/07/07 the following assurance in writing that: “A strategy is now in place to ensure all staff at the home receive regular supervision in accordance with departmental standards and the National Minimum Standards.” On speaking to staff and viewing records we were satisfied that the previous requirement had been complied with. Following the last inspection, a qualified manager who was registered to manage a similar resource, was seconded to oversee the home. This situation remained until just prior to this visit, when a new permanent, qualified and experienced manager was appointed. The new manager had previously been registered at another Hampshire County Council service. The manager’s application for registration by CSCI, is in the process of being applied for. The home now has a clearly defined management structure. The new manager is in the process of producing a comprehensive improvement/action plan that will build on the progress made since the last inspection and will be designed to takes the home forward and further improve the standard of the existing service. Staff spoken with all confirmed they were aware of their responsibilities and the limits of their authority. They described the management team as approachable and accessible and willing to listen to any ideas they may have for the improvement of the service. All felt the home had improved since the last inspection, largely brought about by the management changes made. As part of the homes quality monitoring system, residents are invited to participate in satisfaction surveys. The views expressed in the surveys are seen as key in highlighting areas that may require improvement or attention and the future development of this service. Currently resident’s relatives and visiting health and social care professionals are not asked for their views. The manager gave a verbal undertaking that the surveys will be expanded to include these groups. We checked a sample of records chosen at random of the records and monies held for safekeeping, on behalf of residents. All receipts for monies spent were available and the cash balances accurately matched with the records. A health and safety policy was in place to ensure the day-to-day safety of residents and staff. Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 23 Procedures include regular health and safety checks, the regular servicing of equipment, staff training in the techniques of moving and handling, infection control, control of substances hazardous to health (C.O.S.H.H.) first aid, health and safety, reporting accidents and the procedures to follow in the event of fire (including evacuation). It was noted that radiators and hot pipes were covered to protect residents from scalding and burns. Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 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 X X 3 Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Bishops Waltham House DS0000038911.V363536.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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