Care Home: Cornwell House

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What the care home does well We were told that routines are very flexible and visitors are made welcome at any time.People have their needs assessed before they are offered a care service at the home and there are opportunities for people to test-drive the service for periods of respite care and visits. People spoken with knew whom they would talk to if they were unhappy and staff were aware of safeguarding procedures. People are encouraged to make their bedrooms their own and bring familiar items and furniture to put on display in their rooms. Communal areas are well maintained and arranges in a homely comfortable way. What has improved since the last inspection? Pre admission assessments are now being carried out so that people moving into the home can be assured that the service can meet their individual needs and preferences. Care plans have improved with a new version in place, which provides better information about how people`s needs should be met. The registered manager told us in the AQAA, which she completed in April 2008 that "the last Quality Control questionnaire highlighted the need for the complaints procedure to be more obvious" She, told us that this had been adressed. We saw the complaints proceedure on display. The AQAA completed by the registered manager in April 2008 informed us of improvements to the environment, which included: One of the bathrooms had been refurbished in December 2007. The patio door had been replaced with double doors and the threshold lowered to give better access to the garden. The kitchen floor had been replaced and a new workstation was installed. Other improvements included a hoist and hoist training for staff. Improvements to the induction of new staff have also been implemented. CARE HOMES FOR OLDER PEOPLE Cornwell House 23-25 Beehive Lane Ferring Worthing West Sussex BN12 5NN Lead Inspector Diane Peel Unannounced Inspection 09:30 10th July 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 Cornwell House DS0000014472.V367387.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. Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cornwell House Address 23-25 Beehive Lane Ferring Worthing West Sussex BN12 5NN 01903 240313 01903 240313 abbeyferring3@btconnect.com 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) The Abbeyfield Ferring Society Mrs Karen Harman Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th March 2007 Brief Description of the Service: Cornwell House is a care establishment providing personal care and accommodation for twenty older people. A voluntary organisation, The Abbeyfield Ferring Society owns the home. The two storey detached building is located in a residential area close to local shops and the sea front. There is a level enclosed garden to the rear of the property and further gardens and ample parking to the front, all of which are accessible to service users. All of the establishment’s bedrooms are for single occupancy and have ensuite facilities and there is communal space for use by people who live at the home on both the ground floor and second floor. The registered manager who is in charge of the day-to-day running of the home is Mrs Karen Harman and the responsible individual acting on behalf of The Abbeyfield Ferring Society is Mr Alan Frost Fees range from £470 to £490 per week. Cornwell House DS0000014472.V367387.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 quality outcomes. Mrs Diane Peel carried out this unannounced visit to Cornwell House on the 10th July 2008. During this visit the intended outcomes for 29 standards were assessed; these included the key standards for care homes providing a service to older people. The Annual Quality Assurance Assessment (AQAA) was returned to The Commission for Social Care Inspection (CSCI) prior to this visit to the home and this was used to address areas of improvements during the inspection process. During the course of the visit we met with people living at the home to discuss their experiences of living at Cornwell House and spoke with staff who told us about their experiences of working at the home and the training provided and the process of recruitment. We had Have Your Say surveys returned by eight people living at the home and six staff working at the home who all gave positive comments about Cornwell House. Two people made some suggestions of how things could be improved and this was fed back to the most senior person who has the role of Head of Services for the organisation along with other issues during our visit because the registered manager was on holiday. A case tracking exercise was undertaken for three people living at the home to see how the assessed needs of these people were being met. We looked at other records in the home at random to make sure that the homes record keeping and working practices promote and protect people living at the home. What the service does well: We were told that routines are very flexible and visitors are made welcome at any time. Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 6 People have their needs assessed before they are offered a care service at the home and there are opportunities for people to test-drive the service for periods of respite care and visits. People spoken with knew whom they would talk to if they were unhappy and staff were aware of safeguarding procedures. People are encouraged to make their bedrooms their own and bring familiar items and furniture to put on display in their rooms. Communal areas are well maintained and arranges in a homely comfortable way. What has improved since the last inspection? What they could do better: Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 7 Two people living at the home suggested that lunch and supper times were too early. This is an area, which could be improved for individual people. Although for most people living at Cornwell House daily living and social activities were to their satisfaction two people returning Have Your Say surveys to us told us that they would like more to do. For some people improvements could be made in this outcome area. Whilst the home encourages people to self administer medication and risk assessments are in place, the registered person must be proactive in making sure that storage facilities provided can accommodate the medication supplied. 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. Cornwell House DS0000014472.V367387.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 Cornwell House DS0000014472.V367387.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): 3,4,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed prior to them moving into the home; people have information available to them and the opportunity to visit the home so that they can make a choice about moving into the home. EVIDENCE: During our visit to Cornwell House we saw the pre assessments for three people. One assessment had been carried out the previous week by two senior care staff for a prospective person who had been enquiring about coming to live at the home. Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 10 The person assisting us on the day of our visit to Cornwell House told us that they had visited this person to carry out the assessment. We spoke to people living at Cornwell House about moving into the home. One person told us that “Karen” (the manager) had visited them at own home. That they had been to look around Cornfield House with their daughter before deciding to move in. One the day of our visit their were two people having respite care at the home and one person who we spoke to told us that they had already been for respite care at Cornwell House so that when they needed to move into a care home they already knew Cornwell House we be alright for them. The AQAA completed by the registered manager in April 2008 said: “Each service user will be assessed prior to admission to ensure that the home will be able to meet their needs. There is a one month trial on both sides which ensures that there is an opt out to both the service user and the provider. No service user will be made promises of services that cannot be met. Service users who are admitted for respite care are given the same options and information. Those admitted for respite care will be informed of the homes policy regarding maintaining their independence, to ensure that they will be able to maximise this when they return home.” Out of the eight people living at the home who returned Have Your Say surveys to us seven said that they had enough information about the care home before they moved in one person said no they didn’t have enough information. A statutory requirement made at our last visit to the home in March 2007 to ensure that people’s needs are fully assessed prior to the moving to Cornwell House is now met. Intermediate care is not offered at Cornwell House. Cornwell House DS0000014472.V367387.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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples changing needs are identified in their individual care plans. People are encouraged to make decisions about their lives and are supported to take risks so that they can retain as far as possible an independent lifestyle. EVIDENCE: Since we last visited Cornwell House in March 2007 we have been told that there have been improvements to the care plans used in the service. The registered manager told us in the AQAA completed in April 2008: “On the last inspection it was highlighted that some aspects of the care plan needed to be reconsidered. The care plans have been changed to make them a complete Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 12 document for each resident. The care plans are constantly under review and any identified requirements will be implemented.” During this visit to the home we looked at the care plans and associated records for three people who we also met during our visit. The plans in place included a personal profile, daily care needs for support with personal care, skin, hands and feet, mobility, food and diet and medication . There were also nutritional assessmenst,falls risk assessments,moving and handling assessments, sleeping assessments,fire risk assessments and where appropriate self medicating risk assessments. The statutory requirement made during our last visit to the home to ensure that care plans “contain clear guidance for staff about how to met the residents’ needs and minimise risks including emotional, mental health, spiritual and social needs. The care plan should be clear, drawn up by staff trained to do so and should be based on professional assessment where available. It should be used by all care staff.” is now met. Daily records observed showed that staff monitor the health and welfare of people living at the home and both these records and additional records for recording visits by health care professionals showed that when people had had access to other health care professionals. Medication was observed to be stored in two locked trolleys securely attached to the wall. There were samples of the signatures of staff that administer medication in the medication records file and we saw that medication records were completed up to the date of our visit. The registered manager told us in the AQAA completed in April 2008: “Where possible we allow residents to take responsibility for their own medication. Residents are protected by the homes policies and procedures for dealing with medicines.” On the day of our visit we case tracked a person who had just moved into the home who also had a risk assessment for self-medication in their care plan. The risk assessment was well documented and risks identified but when visiting this person’s room we saw that the lockable storage space already provided was not large enough to accommodate blister packed medication, which we were told, had been delivered the previous day. This medication had been left on the windowsill of the bedroom and the door left open. Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 13 We spoke with the most senior person, the Head of Services on behalf of the organisation, who was also present in Cornwell House during our visit, about the risks, which this could cause. They agreed to rectify the matter immediately and a larger metal storage box was provided within an hour of bringing this matter to their attention. The supplying pharmacist had carried out an advisory pharmacist visit on the 5/6/08 and we saw in the services quality assurance documentation how recommendations by the pharmacist had been implemented. People living at the home who returned surveys to us on the whole were satisfied with their level of support that they receive, with six people telling us that they always received the support that they needed and two people telling us that they usually received the support that they needed. Other healthcare professionals outside the home provide medical support and for the majority of people they thought that they usually received the medical support, which they needed. Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 14 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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The interests of people living at the home are recorded and they are provided with opportunities to take part in recreational activities and maintain contact with their family and friends. EVIDENCE: During our visit to Cornwell House we saw that peoples interests prior to them moving into the home had been recorded. We spoke to people about their lifestyle at the home and the flexibility of the home. They told us about the accordion playa and guitar player and singer who visit the home. Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 15 The schedule of activities, which we saw on the notice board, also advertised, music for health and a clothes party. The AQAA completed by the registered manager in April 2008 also told us about the beetle drives and bingo organised at the request of people who live at the home, this was confirmed by people who we spoke to in the lounge who told us about the bingo which they liked to play after lunch on a Sunday. One person who we spoke with in their room told us that they had been to the music for health the previous day and that they liked the music from the violinist and the accordion playa. During time that we visited people in their rooms we saw people doing crossword puzzles, reading newspapers and knitting materials were observed for a person who we were told by staff had gone to a day centre. We were told that one person goes to a day centre for two days and another for one day. Have your say surveys returned by eight people in the home reported that activities are usually provided at the home but for one person had made an additional suggestion of more activities and entertainment another person said “I would like more activities for residents.” The AQQA completed by registered manager in April 2008 had already identified that improvements to social activities could be made and local outings are being considered. People living at the home that we spoke with during our visit were satisfied with the arrangements for visitors to the home and the visitors book showed frequent visitors. We joined people for the main meal of the day in the dining room. The meal was roast chicken, broccoli, carrots and roast potatoes followed by chocolate gateau and cream. Some people were observed to take an alternative of yogurt or fruit or both. Tea and coffee was offered after the meal. We asked staff and people living at the home about how people make choices about what they wanted to eat. We were told that on the previous day a member of staff goes round with a clipboard and informs people what the choice of meals are for the next day. They then record what people have chosen but there are always alternatives of fish, omelettes, jacket potatoes, salads or soups. The supper usually includes one main option with choices of sandwiches of alternatives. Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 16 For the majority of people who we either spoke to during our visit or who returned Have Your Say surveys to us the standard of meals and opportunities for choice and variation were good with comments received such as: “Meals seem well prepared and presented, drinks and biscuits always available”, “very good choice.” For two people comments were received about the timing of the meals “lunch at 12pm and supper at 5pm is too early. They should be delayed by 30 minutes” and supper is too early. This is an area of further improvements, which was discussed with the Head of Services after our visit to the home. Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 17 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear procedures for responding to complaints and safeguarding adult’s matters so that people can feel safe and know that their concerns and welfare are taken seriously. EVIDENCE: The registered manager told us in the AQAA which she completed in April 2008 that “ the last Quality Control questionnaire highlighted the need for the complaints procedure to be more obvious. This has been addressed.” We observed during our visit that the complaints proceedure was prominantly displayed on the “serice users notice board.” The homes quality assurance system includes records of complaints made and were saw that the registered manager had completed audit trails on complaints to make sure that they had been dealt with appropriately. Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 18 The AQAA returned to us by the registered a manager gave us some data about complaints received. In the past year twelve complaints had been received of which nine had been upheld. Seven out of the eight people using the service who returned Have Your Say Surveys to us told us that they knew how to make a complaint and one person said they didn’t. When asked the question “ do you know who to speak to when you are unhappy about something” five people said that they did and three people said usually. We have not received any concerns about the service either through complaints or safeguarding adults. The home has safeguarding adults procedure which its uses in conjunction with the West Sussex Multi Agency Safeguarding Adults procedures. Data provided by the registered manager in the AQAA returned to us told us that the homes own policy was last revised on the 1st April 2008 and that the service had also made one safeguarding adults referral. We were told during our visit that some staff had had safeguarding training and that another course was being booked. The AQAA completed by the registered manager in April 2009 said “ Staff are aware of the need to observe for signs of abuse and to report any suspicions immediately. Staff are given training in adult protection and are checked through the Criminal records Bureau prior to appointment.” Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 19 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): 19-26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Cornwell House is comfortable, clean and well maintained so that people have a home from home environment to enjoy. EVIDENCE: We looked around the home during the visit to Cornwell House and saw that everybody living there had well maintained single en suite accommodation. We saw that many people had brought pieces of furniture from their own homes and staff told us that this was encouraged. Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 20 We spoke to people living at the home who told us how pleased they were with the home and how clean it was kept. Have your say surveys returned by seven people living at Cornwell House told us that in these peoples opinions the home was always clean and fresh. One other person told us that it was usually kept clean and fresh. Communal areas visited were homely and well maintained. People have a wellkept garden to enjoy. The AQAA completed by the registered manager in April 2008 informed us of improvements to the environment, which included: One of the bathrooms had been refurbished in December 2007. The patio door had been replaced with double doors and the threshold lowered to give better access to the garden. The kitchen floor had been replaced and a new workstation was installed. Other improvements included a hoist and hoist training for staff. Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 21 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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have a consistent, well-trained staff team to assist them to remain safe and as independent as they individually require. EVIDENCE: Staff rotas were observed to be on display in the office and staff who spoke with told us that there are two care staff and a senior care staff on duty in the morning and afternoon. Two staff work at night. In addition to care staff during the daytime the home has a “home companion” each weekday to help out with coffee, teas and lunch. This allocated persons main role is to offer social support to people. We looked at the recruitment record of three staff during our visit. Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 22 There was evidence of current Criminal Record Bureau (CRB) and Protection of Adults (POVA) but in some cases we could see that people had started work before their CRB and POVA disclosure had been received. We discussed this matter with the Head of Services acting on behalf of The Abbeyfield Ferring Society during our visit who we reminded that people must have at least a POVA first clearance before they start work and then they must be supervised until a full disclosure is received. They told us that this is now the practice being undertaken when recruiting new staff. A job application was on file, two references; evidence of verification of identity had been confirmed for all three staff for whose recruitment documents were viewed. When asked in the staff Have Your Say surveys “ Did your induction cover everything you needed to know to do the job when you started? four staff returning surveys reported very well and two staff reported mostly. All six staff returning surveys reported that that they were being given training relevant to their role, which helped them understand and meet the needs of individuals who they work with and keeps them up to date with new ways of working. All six staff returning surveys said that they regularly met with their manager for support and discussion about how they work. The AQAA completed by the manager in April told us what improvements had been made: “The need for a more robust induction programme was identified at our last inspection. We have addressed this. A training matrix has been established to identify when training is due. A matrix has also been established for appraisals. We have used the Common Induction Standards as a basis for our induction programme. Data provide in the AQAA also told us that eleven staff had an NVQ at level 2 or above and that three staff were working towards an NVQ at level 2 or above, a total of 50 . Training records and a training matrix observed during our visit to the home showed us that staff are provided with training relevant to their jobs. A statutory requirement made at the last visit to the home in March 2007 to ensure that “staff receive formal and recorded induction training in line with current recommended guidelines” is now met. Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 23 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): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to ensure the home is well managed and people living at the home are consulted so that they know that the home is being run in their best interests. EVIDENCE: Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 24 The manager was registered with us in October 2007 and has worked within the care sector for many years as a nurse or manager and has previously been a registered manager of a care home. The AQQA completed by the registered manager in April 2008 said.” The residents are protected where the home manages money on their behalf. There are good policies and procedures in place. Records and receipts are kept for all transactions.” The Head of Services acting on behalf of the organisation told us that there had been no changes to the systems in place to manage people’s monies. Information provided in the AQAA returned to us told said: “The findings of a recent Quality Assurance audit have been acknowledged and, where appropriate, changes have been made, or planned for. Residents are consulted about the way the home is run.” During our visit we saw the results of the homes own quality assurance systems and saw quality audit checks being carried out on the service. We saw minutes of meeting with the people who live at the home and people who work at the home to show that they are involved in the running of the home. We sampled equipment maintenance records during our visit and other data in the AQAA completed by the registered manager in April 2008 showed us that equipment and services had been tested a or serviced as required. Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 25 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 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 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 Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 26 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 Cornwell House DS0000014472.V367387.R01.S.doc Version 5.2 Page 27 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. 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