Care Home: Cheveley House

Similar services:

• The Highlands
• Turret Villa Retirement Home
• Blenheim House
• 1 Lanark Close
• Mendip House
• Beaconsfield Court Care Home
• Ann Charlton Lodge

What the care home does well What has improved since the last inspection? There were no areas where the home was below the minimum standard at the last inspection. CARE HOMES FOR OLDER PEOPLE Cheveley House Cheveley Park Estate Belmont Durham DH1 2AD Lead Inspector Steve Tuck Key Unannounced Inspection 19th May 2008 10:00 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 Cheveley House DS0000031184.V365889.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. Cheveley House DS0000031184.V365889.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cheveley House Address Cheveley Park Estate Belmont Durham DH1 2AD 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) 0191 3863787 0191 3860804 brenda.mason@durham.gov.uk www.durham.gov.uk Durham County Council Brenda Mason Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability (8) of places Cheveley House DS0000031184.V365889.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th May 2006 Brief Description of the Service: Cheveley House is a care home situated in the Belmont area of Durham which provides accommodation and personal care for thirty eight people. The home cannot provide nursing services but people can be supported by community nursing staff visiting the home. The building is in a well-established residential area amongst residential properties of the same age built nearby. There are three areas of the home which provide for people who need a short term stay, those recovering from illness or accident and needing therapy or treatment to help them regain their independence and, on the first floor people who live at the home on a permanent basis. The service is operated and managed by Durham County Council who have owned the home since it was built in the 1970’s. The building provides 38 single rooms and there are also communal toilets, showers and bathrooms, situated throughout the building, which are fitted with adaptations to help people who are frail or have a physical disability. Each floor has several lounge and dining areas which have been set out to make best use of the daylight and views of the gardens and the surrounding village. On the ground floor the home has a separate day centre in a large lounge which is used by some of the people living at the home. There are car parking spaces at the front of the building including disabled parking bays near the entrance. There is easy access into building through the main doors into the reception area. Cheveley House is a short walking distance from local shops, is a short bus or car ride from Durham City Centre. There is access to local transport directly outside the building. The weekly fees for living at this home are between £0 to £364. The costs of newspapers, hairdressing, private chiropody and toiletries are not included in the fees. Fees vary depending on people’s circumstances, further details can be found in the home’s Service User Guide. This inspection took place over three days and was a scheduled unannounced inspection. Cheveley House DS0000031184.V365889.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. Before the visit: We looked at: • Information we have received since the last Key Inspection. • How the service dealt with any complaints & concerns since then. • Any changes to how the home is run. • The provider’s view of how well they care for people. We asked them to examine their own service and write to us with the results. • The views of people who use the service, their relatives and staff by questionnaire. Twenty one people replied. The Visit: An unannounced visit was made on 19th May 2008. During the visit we: • Talked with the people who use the service, the staff and the manager. • Observed life in the home. • Looked at information about the people who use the service & how well their needs are met. • Looked at other records, which must be kept. • Checked that staff had the knowledge, skills & training to meet the needs of the people they care for. • Looked around parts of the building to make sure it was clean, safe & comfortable. • Checked on what improvements had been made since the last visit. We told the manager what we had found. What the service does well: Cheveley House is a well-established care home. People who live there said good things about the care they receive. Many of the agency’s strengths were expressed in the comments that people gave and they said that they are involved in the planning and delivery of their care. As well as providing long term care for some, this home successfully helps people to recover from illness Cheveley House DS0000031184.V365889.R01.S.doc Version 5.2 Page 6 or injury and over 70 return home, and others move there for a short term breaks so that they can continue to live on their own or with help. General comments included: • • • • • “I enjoy coming to the day centre.” “The service is excellent – I have no complaints at all.” “Good meals.” “Good activities – lots of nice things (to eat).” Care is provided to people with a wide range of needs, with varied ages, expectations and backgrounds. This diversity, including age and gender, is reflected in the staff team, giving the opportunity for staff to be ‘matched’ to people where appropriate and this was confirmed in their comments. Both care practice and staff recruitment practices are governed by equal opportunity principles. People who live at the home said they were happy with the staff who offer care. People’s independence is promoted and the care received is flexible and reliable. For example people said: • • • “I am very happy with the care and attention I receive.” “They’re angels I’d never be going home on Thursday without the support they’ve given me.” “They’ve helped me to walk again – I feel confident.” Staff have undertaken qualifications in care and are provided with some specific training to help them develop the knowledge, skills and confidence to support people. Staff are well organised by their manager, with good communication and record keeping. This helps staff to organise their work routines, and know how to meet the needs of the people they are to support. The home is managed in a way that makes sure that staff know peoples routines and how the activities at the home can to help people to be involved, motivated and interested. There is a good atmosphere at this home and everyone is included in the dayto-day options and activities if they wish. Relatives were complimentary about the service. They said: • • • “ This is the right place for my mam.” “I am very happy with the care they give my mother and she is very happy here.” “Staff carry out care in a dignified manner.” People living at the home are complimentary about the staff and manager and felt that their views were listened to. The manager makes sure that people are asked for their views and these are used to verify that the home is working to Cheveley House DS0000031184.V365889.R01.S.doc Version 5.2 Page 7 improve their lives by providing good quality support. The home has received an Nationally accredited award in customer services called a Charter Mark and has been commended by the Prime Minister. People who live at the home are protected, they are safeguarded from abuse by staff who are trained to look after their best interests. If people have complaint then these are taken seriously and properly responded to by the homes manager. People living at the home benefit from well-trained staff, many of whom have worked at the home or with Durham County Council for a long time and get to know people well. Staff receive good levels of training with almost all having an NVQ level 2 or above. And the County Council has carries out lots of other training which helps staff to develop best care practices so that they have the right skills to support the people who live at the home . 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. Cheveley House DS0000031184.V365889.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cheveley House DS0000031184.V365889.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Trained staff from the home find out and understand the needs of people who wish to live there before they move in. This information helps to make sure that peoples needs can be met at the home and agree the ways in which agency staff are to support them. EVIDENCE: People who live at the home have a signed agreement about the purpose of their stay, proposed length of stay, and fee levels. This should help them to understand their rights and the homes responsibilities. By looking at the record kept at the home we could see that each persons needs are assessed before they move to the home, either by a local authority social worker, the manager, or by both. This is so that the acting manager can Cheveley House DS0000031184.V365889.R01.S.doc Version 5.2 Page 10 be sure that the home is suitable for meeting the needs of people who are going to live there. The manager also finds out the cultural and lifestyle needs of people who wish to move to the home to make sure that these can be met. She does this by asking about their backgrounds and how they expect that the home will meet their cultural needs. The manager and senior staff have also been trained so that they are able to find out what peoples needs are. And the council has recently improved the way that social workers look at peoples needs so that these are clearer. As a result of these measures, all of the people living at the home at present have been properly placed and the home is able to meet their needs. People can be admitted to one part of the home that concentrates on helping them to regain their independence. People stay at this part of the home for a short period while they get special therapy, support and care while they recover from injury or hospital treatment. People in this part of the home have a variety of needs for example, they may have had a hip joint replacement operation or are recovering from an accident or illness. The manager is able to gets good assessment information advice, guidance and support from other healthcare specialists so that people can be successfully treated whilst they are at the home. One man said, “ When I got here it was reassuring that they seemed to know everything about me – I couldn’t have done without them” A visiting therapist said, “It’s a good service, I know they will do everything they can to support residents to get back to their homes.” Cheveley House DS0000031184.V365889.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s care and health needs are supported by the home and the way that staff give out medication helps to make sure that they get the medical treatment that has been prescribed. And every person has a plan of their care which shows how their individual assessed needs and personal goals will be met and gives the care practice guidance that staff need. EVIDENCE: Every person has an individual plan which records what the home will do to support them. All of these plans give a detailed description of the support that people need although some have more information in them than others. Staff at the home know lots about the needs of people who use the service and how they prefer to be supported. Two staff were asked in detail about the ways that they support people and both could describe the needs of the people they care for in a lot of detail which matched the descriptions written in their care plans. Cheveley House DS0000031184.V365889.R01.S.doc Version 5.2 Page 12 Staff use care plans as a way of monitoring the progress that people make as they recover from an illness or incident. They use plans and reviews of people’s progress to work alongside nurses and therapists and decide about the next stages of peoples recovery support. People that live at the home mentioned that they had a care plan ‘file’ which the staff use to record important information with them. One person said, “ They have everything in the book – It helps them to remember the important things about me - a bit like my doctor does.” Another said, “I can look in my file with the staff to see what is happening.” People who live at the home and their relatives made positive comments about the approach of staff and they stated they are treated with courtesy and that staff are always polite. Those asked said that staff upheld their privacy, which is promoted by a stable staff team who know the people they care for well. Staff were seen to knock on doors before entering, talk to people in a respectful way and call them by the names or titles they prefer, all of which are good practice. Staff are also trained and monitored to make sure that the homes policies on privacy and confidentiality are maintained. All people who use the service who were interviewed or send in a questionnaire made positive comments about the service they received and how staff and the support from the home helped them to remain as independent as possible and for some, return to their own homes. The home also helps people to exercise their rights by giving the details of other support available, for example advocacy services. Due to their levels of need, some people who live at the home are not able to organise their own medicines, and appointed staff therefore help in this area. Staff at the home have been trained so that they know the best ways to store and give out medication. Medication is securely stored and apart from two mathematical errors caused by not returning unused medication to the pharmacist, all other records were accurate showing that the amount of medication prescribed is given out to people. Cheveley House DS0000031184.V365889.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. People who live at the home are encouraged and supported by the staff to lead fulfilling lives with their rights as individuals being respected and to eat healthily which supports their physical and emotional wellbeing. Contact with family members and friends are supported where possible so that people keep up links with those outside the home. EVIDENCE: People talked of the things that they do both inside and out of the home, in the local and wider community. For example games sessions, shopping visits, social events and entertainment. There are photographs of celebrations and events and people and their relatives talked about these. Visits and days out in the summer weather were talked about by people living at the home and the manager confirmed that she hoped to be able to do more of these this year. Cheveley House DS0000031184.V365889.R01.S.doc Version 5.2 Page 14 For some of the people who are unable or do not wish to leave the building there are activities taking place. People living at the home said, “When people get together in the lounge its always a lively place.” “I like the quiet lounge where I can sit with my friends we feel like we’ve known each other for years.” “It’s my home and I’m very happy here.” “Its nice being able to go outside sometimes.” People living at the home are encouraged to make choices about their diet. Most said that they like the meals at the home and that they are asked what they would like to eat. Staff were seen asking people about their choice of meal, size of portion to make sure that they always had their choice of meal. Comments from some of the people living at the home were, “I like the food, they ask me what I want.” “They will always make sure there is something you like to eat.” Staff are available during meals to offer support and assistance where needed and this makes meal times a relaxed and unhurried experience. Both of the cooks have extensive knowledge of the meals which people living at the home prefer and make sure that that only good quality ingredients are used to prepare meals. Menus were available which confirmed that a range of meals are provided which give people a balanced diet and refreshments are available throughout the day and night. People living at the home and their families are involved in choosing the meals that are included in the menu. Where people need it food supplements are available to help people to maintain their health for example if they have diabetes or have difficulty maintaining their weight. Cheveley House DS0000031184.V365889.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. People living at the home and their families can make a complaint if they are unhappy, have a grievance or dispute which helps them to have control over their lives and there are measures in place which protect people who live at the home from being harmed which helps to promote their safety and security. EVIDENCE: There is a thorough complaints procedure which tells people what to do if they are not happy. This informs people about who they should make a complaint to and how much time that a complaint will take to look at. There is a record kept at the home of all complaints, which includes details of any investigation and the outcome. All of the people who live at the home who were asked said that they were aware of who to contact if they wanted to complain about their service. No one has approached the Commission for Social Care Inspection (CSCI) because they have been unhappy with the way that the home has managed their complaint. One person living at the home said, “I would just see the manager if I had a problem – I’ve known her for years.” Whilst there have been no instances where abuse has taken place or been suspected, the home has an adult protection procedure which can be used Cheveley House DS0000031184.V365889.R01.S.doc Version 5.2 Page 16 where necessary to protect people living at the home. Staff have guidance and training about what to do if they see or suspect abuse is taking place and all staff spoken to showed that they knew what to do and what they expected to happen so that people remain protected. Cheveley House DS0000031184.V365889.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. People live in a homely, clean and comfortable environment, which promotes their privacy, independence and comfort during their stay at the home. The home is clean, pleasant and hygienic which supports the health and lifestyles of people living there. EVIDENCE: All communal areas and some of the bedrooms were viewed during the inspection. The home has had recent repairs and there is ongoing maintenance taking place. The home has been adapted so that all the people who live there can have safe access to the areas where they live. Everyone is able to lock their bedroom Cheveley House DS0000031184.V365889.R01.S.doc Version 5.2 Page 18 doors so that they can have privacy and there are areas where people can meet and talk in private. There are large gardens which the manager is hoping to have landscaped and get better maintenance so that people will be able to use the outside spaces more often. The bedrooms are pleasant areas, which have a useful range of comfortable furniture and fittings. Most people have decorated their rooms with their items, photographs and keepsake’s. There are enough toilet and bathrooms available, some of which have been changed to help people who have mobility needs to use them. The home is kept clean by staff who take effective steps make sure that there are no unpleasant smells. The home is over 30 years old and was built to meet previous standards of space and convenience. The manager has drawn up a programme of future developments and repairs are allocated on a priority system for this building. The manager and the council have done well to continue use their ingenuity with limited finances to continually adapt and maintain the building so that it remains fit for it’s purpose in meeting people’s needs. There is evidence that the manager has been persistent and largely successful which must be recognised and applauded. Although one washing machine was awaiting repairs, there are laundry facilities are in place to make sure that that peoples clothing and linen is hygienically cleaned and the risks of passing on any infections is reduced. Arrangements are in place to make sure that clean clothing is always returned to their owner and mistakes are avoided. But the amount of laundry has been increased since the home is no longer able to have bed linen and towels laundered by a company outside the home. The home is inspected by the Fire Prevention Authority and the Health and Safety Executive (HSE) to make sure that the building and safety systems are suitable for the protection of those who live and work there. Cheveley House DS0000031184.V365889.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. This judgement has been made using available evidence including a visit to this service. There are sufficient staff working at the home to meet the needs of the number of people who presently live there. The ways that staff are employed makes sure that people are protected and most staff have been trained to make sure that their care practice is good. EVIDENCE: The manager has organised the home so that overall there are sufficient staff available to meet the needs of people who currently live there. But since the last inspection the council has reduced the number of staff hours available to carry out care duties. This is because the council has decided not to send bed linen to be washed by an outside service. The home had previously been staffed sufficiently to carry out personal laundry only for the people living at the home. The change increased the amount of time staff need to carry out laundry duties preventing them from spending that time with people living at the home. One person living at the home said, “Laundry sometimes disappears for ages but it usually comes back eventually.” Cheveley House DS0000031184.V365889.R01.S.doc Version 5.2 Page 20 One staff said, “Sometimes you can walk into the laundry and it is literally floor to ceiling with clothes and bedding.” Staff can describe the needs of people living at the home in detail. They get on well together and with people who live at the home and promote an inclusive and supportive structure. One person living at the home said, “I know them all very well, they make me feel at home and I know if I am upset or worried I can talk to them.” A relative said, “They really do care about people here – they want people to feel content and have a good quality of life in their later years.” Staff spend time with people who live at the home, listening to their opinions and experiences and taking part in discussions and laughing together which creates a happy atmosphere at the home. Staff turnover at the home is very low which gives people who live there and staff the opportunity to get to know each other. Almost all of the staff team have now attained NVQ awards in care at level 2, and some are working towards either Level 2 or 3. There is a plan in place which describes the training which staff are to undertake and is based on their personal training requirements and interests. The home has also achieved a ‘Charter Mark’ in customer services for a second year and has been commended by the previous Prime Minister Tony Blair. The manager makes deliberate attempts to recruit staff from similar cultural backgrounds as the people living at the home. In some cases they share the same community and social links which helps to make sure that people are confident with the way in which they are supported. Looking at staff records for people appointed in the home confirmed that rigorous checks are carried out before they are employed to work there. This includes receiving appropriate references and completing a criminal record check. Staff files contain employment history, records of training and any training certificates. Cheveley House DS0000031184.V365889.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. There is a manager in place who makes sure that people who live at the home are supported properly and gives leadership and direction to staff so that the quality of the service for the people who live there is measured and improved on. EVIDENCE: The manger has many years experience in a number of management roles on which to base her practice and continues to demonstrate considerable knowledge and skill in this care setting. She has undertaken training from time to time to update his knowledge, skills and competence which includes both an NVQ level 4 in Management and in Care. The manager shows her capacity to Cheveley House DS0000031184.V365889.R01.S.doc Version 5.2 Page 22 organise the service on a day to day basis alongside other members of the management team as well as running an effective and successful service. This reassures people living at the home and their relatives that the service can continue to be provided in their best interests. In particular, around 90 percent of the people who move there for recovery successfully regain their independence. The manager collects the views of service users, families and friends so that he can check to see if the service is meeting the needs of all parties. There are a number of meetings held at the home and other informal occasions where the manager is able to check that people are satisfied with the service. This helps the manager to monitor progress and develop the service. There were no noticeable hazards at the home throughout the inspection and arrangements are in place to minimise risks for service users and staff. The home is also subject to inspections by the Fire Authority and local authority environmental health officers to ensure that the home is safe. Cheveley House DS0000031184.V365889.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X 3 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 Cheveley House DS0000031184.V365889.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. Refer to Standard OP7 Good Practice Recommendations It is recommended that when the new care plans have been fully implemented that an audit of the care plans be undertaken to ensure that there are no inconsistencies in their content particularly in the areas of bathing and weight management. Cheveley House DS0000031184.V365889.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Cheveley House DS0000031184.V365889.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!