Care Home: Chandos Lodge

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What the care home does well Information is provided to help people decide if they wish to move into Chandos Lodge. The home carries out assessments of people`s needs before they move in, so that they can be sure that the home is suitable for them. People can be confident that their health and personal care needs will be met by skilled and caring staff. The home manages medication safely. There is a range of social and leisure activities, so that people can choose how they spend their time. Menus are varied and the food is appetising and provides a balanced and nutritious diet. This means that people can be confident that their nutritional needs will be met.People know who to talk to if they have any concerns, and can be confident that these will be taken seriously. The home has thorough recruitment procedures which help to ensure that only suitable staff are employed. The home is safe and comfortable, with a friendly and welcoming atmosphere. It is kept very clean, and infection control is well managed. Staff are kind and caring, and are responsive to people`s individual needs. The care staff are competent and have the skills they need to carry out their roles. The manager is experienced and knowledgeable, and makes sure that the home is run in the best interests of the people who live there. What has improved since the last inspection? The home has made significant improvements to its risk assessment procedures. Care planning is thorough and there is a clear link between identified risks and the way in which care is planned to minimise and manage the risks. The home now has storage for controlled drugs, which meets the legal requirements. The home has made sure that all radiators are safe and do not put people at risk of harm or injury. What the care home could do better: The home should look at signage within the home, to make sure that it is easier for people with a dementia illness to orientate themselves. CARE HOMES FOR OLDER PEOPLE Chandos Lodge 77 Stourbridge Road Hagley Stourbridge West Midlands DY9 0QS Lead Inspector Sarah Blake Unannounced Inspection 20th January 2009 09:15 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 DS0000018463.V373885.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. DS0000018463.V373885.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chandos Lodge Address 77 Stourbridge Road Hagley Stourbridge West Midlands DY9 0QS 01562 885858 01562 887291 chris.bradley@redwoodcare.co.uk 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) Chandos Lodge Ltd Pearl Bartlett Care Home 24 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (24), of places Physical disability over 65 years of age (24) DS0000018463.V373885.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th January 2008 Brief Description of the Service: Chandos Lodge is a large, detached property situated in a semi-rural position on the main Stourbridge Road in Hagley. There are car parking facilities at the front of the premises. The home is currently registered to provide personal care for a maximum of 24 older people who may also have a physical disability. The home is also registered to accommodate up to six people over the age of 65 years who have a dementia type illness. At the time of this inspection building work to increase the number of bedrooms and provide more communal space had been completed. The provider has made an application for the new bedrooms to be registered with the commission. Currently people using the service are accommodated on the ground and first floor of the premises in 18 single bedrooms and 3 double bedrooms. Ten of the single bedrooms have en suite facilities. A passenger lift is installed within the home. A registered manager who is supported by an experienced registered provider manages the home on a day-to-day basis. The schedule of fees is available from the home. Fees do not include the cost of dry cleaning, newspapers, hairdressing and any taxis or escorts. A copy of this report is available to view at the home. DS0000018463.V373885.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 stars. This means the people who use this service experience good outcomes. We spent a day at the home, talking to the people who use the service and the staff, and looking at the records, which must be kept by the home to show that it is being run properly. These include records relating to the care of people who use the service. We looked in detail at the records for two people living at the home. Mrs Pat Whelan, an expert by experience was present for part of the inspection. An expert by experience is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The service had previously completed an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. Some of the manager’s comments have been included within this inspection report. We also received completed survey forms from people who use the service, their relatives and health professionals who work with the home. The information from these sources helps us understand how well the home is meeting the needs of the people using the service. What the service does well: Information is provided to help people decide if they wish to move into Chandos Lodge. The home carries out assessments of peoples needs before they move in, so that they can be sure that the home is suitable for them. People can be confident that their health and personal care needs will be met by skilled and caring staff. The home manages medication safely. There is a range of social and leisure activities, so that people can choose how they spend their time. Menus are varied and the food is appetising and provides a balanced and nutritious diet. This means that people can be confident that their nutritional needs will be met. DS0000018463.V373885.R01.S.doc Version 5.2 Page 6 People know who to talk to if they have any concerns, and can be confident that these will be taken seriously. The home has thorough recruitment procedures which help to ensure that only suitable staff are employed. The home is safe and comfortable, with a friendly and welcoming atmosphere. It is kept very clean, and infection control is well managed. Staff are kind and caring, and are responsive to peoples individual needs. The care staff are competent and have the skills they need to carry out their roles. The manager is experienced and knowledgeable, and makes sure that the home is run in the best interests of the people who live there. 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. DS0000018463.V373885.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 DS0000018463.V373885.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good information to help people decide if they wish to move into Chandos Lodge. People can be confident that their needs will be assessed before they move in, so that they can be sure that the home is suitable for them. EVIDENCE: The home provides a brochure for people who are considering moving into Chandos Lodge. It gives detailed information about life at the home. This brochure is also the Service Users Guide, a copy of which is given to everyone when they move into the home. The manager told us that the Service User Guide will soon be updated to include information about the new extension. DS0000018463.V373885.R01.S.doc Version 5.2 Page 9 In our surveys, people told us that they had been given enough information to help them to make up their minds as to whether Chandos Lodge was the right place for them. One person told us that she moved into the home last year and had looked at lots of places before deciding on this as her new home. We looked at the records for one person who had recently moved into the home. We saw that senior staff from the home had visited to assess the persons needs before they moved in. This assessment was brief, but contained sufficient detail for the home to be able to ensure that it could meet the persons needs. The assessment gave staff useful information so that they could provide the care that was needed as soon as the person moved in. DS0000018463.V373885.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident that their health and personal care needs will be met by skilled and caring staff. The home supports people with their medication needs safely. EVIDENCE: At the last inspection, the home was required to make improvements to the way in which risk assessments and care plans were documented. We looked in detail at the records for two people living at the home. The risk assessments were completed in full, and, where a risk had been identified, the home had clear care plans which explained in detail how the risk was to be managed. DS0000018463.V373885.R01.S.doc Version 5.2 Page 11 For example, we saw that one person had been assessed as requiring specialist equipment for mobility. The care plan included clear and detailed information for staff so that the equipment would be used safely. Another person had been assessed as being at high risk of developing pressure sores. A care plan had been drawn up to make sure that the risk was reduced by the use of pressure relieving cushions and by changing the persons position regularly. We saw that care plans included information about how people like things to be done for them. The home provides care for some people with a dementia illness, and we saw that the care plans for one person with dementia gave clear information for staff, such as staff to talk clearly to X (name of person) in the hope that she understands and ensure teeth are brushed twice daily, explaining actions clearly to X (name of person). In the AQAA, the manager told us that the home “works closely with service users/relatives/staff to ensure effective planning”. We saw that there was a notice on the board in the reception area which stated residents care plans are updated on a monthly basis. If you would like to be involved in this process, please see the manager. The records showed that people or their relatives had signed their care plans to indicate that they had been involved and agreed with the content of the care plans. We saw that the care plans are regularly updated, at least monthly. We looked at the records for someone who has recently had health problems and we saw that the care plans had been updated every time their condition changed, and new acre plans added to address issues such as pain management. A local GP told us in a survey that the home delivers individualised care well and consistently, and a relative told us the staff have been very good at contacting the doctor if necessary. The records showed that medical help had been sought whenever staff had concerns about a persons health and wellbeing. The GP also told us that the home will always ensure that patients are seen in confidential surroundings. The home has good procedures for the safe management and administration of medication. We looked at the medication records for two people, and these were completed fully and accurately. The home has purchased a storage cupboard for controlled medication, which meets the legal requirements. DS0000018463.V373885.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home have access to a range of social and leisure activities. Food is of a high standard, and provides a nutritious and balanced diet. EVIDENCE: The home works hard to ensure that people are offered a choice of activities. The activities notice board near the lounge shows that a range of activities is provided, including bingo; sewing; nail care; sing along; board games, and quizzes. A holistic therapist visits monthly and provides a range of therapies including massage. There is an additional charge for the holistic therapies. The therapies have proved to be very popular with the people living at the home, and one person told us the new massage sessions have been very helpful. An activities co-ordinator is allocated daily from among the care staff. One care worker told us that she enjoys working with people on art and craft DS0000018463.V373885.R01.S.doc Version 5.2 Page 13 activities. Fitness sessions are held monthly, and the library service visits regularly. People who live at the home are encouraged to take part in the activities of daily living, if they wish to, and we saw that one person enjoys folding the clean laundry. Photos displayed on a notice board showed people engaged in activities, such as the annual Christmas party. The manager explained to us that staff are careful to tailor activities to peoples individual needs, especially the specialist needs of people with a dementia illness. We saw that staff were careful to explain the activities carefully and make sure that people were given as much time and support as they needed. On the day of the inspection, three people spent the afternoon baking and decorating cakes for tea, with the support of a care worker. The manager told us that the new extension has a second lounge area which is planned as a “cinema” room. This room will also have computers with internet access. The manager told us that a large plasma TV is on order and film nights are planned, which will include pop corn and pizza. The plans have been discussed at the monthly residents meeting, and some of the people living at the home told us that they were getting together to draw up a few suggestions for old films. We saw that the menus provide a balanced and nutritious diet, and the chef showed a good understanding of the dietary needs of older people, including people with diabetes. Lunch on the day of the inspection was gammon or minced lamb pie, with fresh vegetables, followed by apple crumble or rice pudding. Supper was egg and cress or tuna and cucumber sandwiches, or quiche and salad, with fresh fruit to follow. At lunchtime, we saw that staff supported people who needed help with eating in a sensitive and kind way, making sure that they were not hurried, and allowing them to do as much as possible for themselves. The expert by experience ate lunch in the dining room on the day of the inspection. She reported that The dining tables were well spaced with ample room between tables for ease of movement and dignity of private eating space. They were set with nice linen cloths, and pretty plastic mats but with large plastic drinking beakers. This seemed incongruous, and did not meet with my expectations. The tumblers made it feel picnicy and the tumblers seemed too big and difficult for some of the older people with arthritic hands and dexterity difficulties to hold. Condiments were freely available on all tables and our gravy was placed on the table in a gravy boat with a nice large handle, DS0000018463.V373885.R01.S.doc Version 5.2 Page 14 as opposed to everyone having gravy slopped on their dinner regardless of choice. We saw that people had been given their breakfast juice in glasses, rather than plastic beakers. The manager told us that the plastic beakers were used at lunchtime because some people drink a large amount. The use of plastic beakers does not promote peoples dignity. People living at the home told us the food is wonderful here and there is lots of variety and choice and if you don’t fancy what you have ordered you can have something else. It is never an issue and teas, coffees, juice and biscuits are always available: you only have to ask. The homes Food Hygiene certificate dated Jun 2008 was displayed and showed that the home had achieved a very good rating. DS0000018463.V373885.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): 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 clear complaints procedure, which is easily available to everyone who uses the service. This means that people know who to talk to if they have any concerns, and can be confident that these will be taken seriously. The home’s recruitment procedures help to protect people living at the home by making sure that only suitable staff are employed. EVIDENCE: The home has a comprehensive complaints procedure, which is included in the Service User Guide and is also displayed in the reception area of the home. In our surveys, everyone told us that they knew who to speak to if they had any concerns. One person said it is easy to speak to a senior member of staff. Another said Pearl (the manager) and X (the deputy manager) in particular always deal with any problems immediately The home has not received any complaints in the past twelve months. We, the commission, have received one anonymous complaint, which the provider investigated fully. This complaint was not upheld. DS0000018463.V373885.R01.S.doc Version 5.2 Page 16 The expert by experience spent time chatting with the people living at the home, and she commented that It was clear that none of the residents I spoke with felt any reluctance when it came to expressing feelings of pleasure or dissatisfaction. Each one appeared to have an open relationship with the carers on duty. In the AQAA, the manager told us we carry out robust checks on possible employees. We looked at staff records, and found that staff are recruited in a way which protects the people living at the home from unsuitable staff being employed. The home carries out POVAFirst and Criminal Records Bureau (CRB) checks on all new members of staff. POVAFirst checks confirm that a person is not banned from working with vulnerable adults, and are used so that a care worker may start work in a care home before a CRB check has been received. New staff at the home had not been allowed to start work until a POVAFirst or CRB check and two written references had been received. Staff showed a good understanding of the ways in which vulnerable people can be protected from the risk of abuse or neglect. The manager told us in the AQAA all staff are trained in POVA (the protection of vulnerable adults), and training records confirmed this. DS0000018463.V373885.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Chandos Lodge provides a safe and comfortable environment, with a friendly and welcoming atmosphere. The home is kept very clean, and infection control is well managed. EVIDENCE: Chandos Lodge has a welcoming and friendly atmosphere, which is apparent on entering the home. On the day of the inspection, the home was seen to be clean and tidy, and we saw the housekeeper working throughout the day. In our surveys, everyone told us that the home is kept clean and fresh. DS0000018463.V373885.R01.S.doc Version 5.2 Page 18 We saw that some people had brought their own furniture and ornaments to make their bedrooms more homely. Each bedroom has a monthly maintenance schedule on the back of the door, and these were up to date and included all items of equipment within the room. We saw that bedroom doors were numbered, but had no other identification. When people have a dementia illness, it can be helpful to them if they can easily identify their own bedroom. The manager told us that she will look at ways in which this might be done. Bathrooms are identified by a picture of a bath on the door, but toilets, although clearly labelled, have no picture to help people identify them. At the last inspection, the home was required to ensure that action was taken to ensure that all radiators were safe. We saw that all radiators were covered with a safety cover, except for one radiator in a bathroom which is permanently turned off. This bathroom was warm in spite of the cold day. The new dining room is a large and airy room, with well spaced tables and a comfortable seating area at each end of the room. There is a sunny conservatory and a large lounge. The lounge was observed to be well furnished and decorated, with a variety of chairs and sofas appropriate for the people using them. They were arranged in groups so that people could easily chat to each other. There are bookcases in the lounge with a varied selection of books, and several board games and puzzles. Just off the dining room is an activity room where it is planned to have a wide screen on the wall for films, also computers with internet access. The garden is easily accessible, and has a patio area with garden furniture. The manager told us that people living at the home who enjoy gardening are encouraged to take part in looking after the garden. The home has a payphone on the upstairs landing, and the manager told us that a separate handset can be used in peoples bedrooms if privacy is needed. During the day of the inspection, we saw that staff were practising good infection control by the use of gloves and aprons, and by thorough hand washing. We spoke to two members of staff, who both showed a good understanding of the principles of infection control. DS0000018463.V373885.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff have the skills and knowledge they need to provide a high standard of care to the people who live at Chandos Lodge. The home provides a good level of training and support for staff. Staff are kind and caring, and are responsive to peoples individual needs. EVIDENCE: The staff at the home are undoubtedly one of its major strengths. One person told us the staff are always very friendly and the home has a family atmosphere. Another person described the staff as very respectful and caring but very loving, treating you as if you were a relative, they really care. In our surveys, everyone told us that staff listen to them and act on what they say. A relative told us I have had immediate action on some comments I have made. The expert by experience spent time in the lounge and the dining room, and she observed The care staff were seen to be discreetly vigilant at all times, DS0000018463.V373885.R01.S.doc Version 5.2 Page 20 always speaking to rather than over or around the residents and, for example, when collecting one person for her hair appointment upstairs, the care worker was seen to crouch down next to her and quietly remind her not to forget to pull her slippers on at the back or your feet will get cold. We looked at staff records and saw that all the necessary pre-employment checks had been carried out before new staff were employed at the home. The manager told us that she would like to look at ways in which people living at the home can be involved in recruitment of new staff. In the AQAA, the manager told us all staff receive induction training and regular mandatory training. The records showed that the home provides a thorough induction for new staff, in particular those who are new to care work. We saw that senior staff had supervised a new member of staff on several occasions to make sure that she was providing care to a good standard. Records showed that staff receive all the necessary training to enable them to carry out their roles. We looked at staffing rotas, and these showed that there are sufficient staff rostered on duty day and night to meet peoples needs in a timely manner. In our surveys, people told us that there are enough staff to meet their needs, and that staff respond quickly when needed. DS0000018463.V373885.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interests of the people who live there. EVIDENCE: The home is managed by an experienced and competent manager, who works hard to ensure that the home is run in the best interests of the people who live there. Throughout the day of the inspection, we saw that there is an emphasis DS0000018463.V373885.R01.S.doc Version 5.2 Page 22 on treating each person as an individual and on knowing each persons needs and preferences. The company carries out its own quality assurance by means of regular satisfaction surveys to people living at the home and their relatives. We saw that the last surveys were from September 2008. They showed that people are very satisfied with the home, and included comments such as Pearl and her staff are always very kind to the residents and create a warm and caring atmosphere. We saw cards of thanks which had been sent to the home, and the comments in these showed that people appreciated the care that had been provided to them. The companys quality manager visits the home regularly, and was at the home on the day of the inspection. We saw that she has produced clear guidance for the home on areas for improvement, and that these are regularly monitored. Staff told us that they consider the manager to be very supportive. One member of staff told us if there was a problem, I could go to Pearl. The home has good procedures for ensuring the health and safety of the people who live there. The home does not routinely take responsibility for peoples day to day finances. The manager completed the AQAA in full and sent it to us promptly. The AQAA contained useful information, and clearly showed that the manager recognises areas where the home could make improvements. DS0000018463.V373885.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 3 X 3 3 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 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 DS0000018463.V373885.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP15 OP21 Good Practice Recommendations You should replace plastic beakers with more suitable drinking glasses. You should review signage within the home, to take into account the needs of people with a dementia illness. DS0000018463.V373885.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 DS0000018463.V373885.R01.S.doc Version 5.2 Page 26 - 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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