Care Home: Crossley House

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What the care home does well The homes assessment processes and the information available about the home ensures that placement is offered to those people whose needs they can meet. People who live in this home will receive the care and support that they need because of the homes care-planning processes. Medication procedures are safe. The people who live in this home will be able to participate in a range of meaningful activities and spend their time as they wish. They are provided with well-balanced and nutritious meals. Residents can be assured that any complaints they have will be listened to and acted upon and that they will be safeguarded from harm. Crossley House is a very homely, safe, comfortable and warm home, and it is fully equipped to meet their needs of the people who live there.The people who live in this home are cared for by skilled staff who are trained and competent to meet their care needs. Recruitment procedures are safe. The people who live in Crossley House will live in a home that is safe and run in their best interests. What has improved since the last inspection? Recruitment practices have improved and all information obtained during the recruitment process, is retained in the home. This provides the evidence that the home follow robust recruitment procedures, and that the people who live in the home will be cared for by suitable workers. What the care home could do better: Formal staff supervision must be improved, although informally this is in place. The manager is aware of this shortfall. CARE HOMES FOR OLDER PEOPLE Crossley House 109 High Street Winterbourne South Glos BS36 1RF Lead Inspector Vanessa Carter Key Unannounced Inspection 28th December 2007 09:30 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 Crossley House DS0000003318.V352829.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. Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Crossley House Address 109 High Street Winterbourne South Glos BS36 1RF 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) 01454 777363 sam.hawker@blueyonder.co.uk Willcox Bros Ltd t/a Ablecare Homes Mrs Jacqui Woodman Care Home 17 Category(ies) of Dementia - over 65 years of age (5), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (17) Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate up to 17 persons aged 65 years and over requiring personal care only May accommodate up to 5 persons with dementia May accommodate one person with learning difficulties Date of last inspection 22nd August 2006 Brief Description of the Service: Crossley House is registered with the Commission for Social Care Inspection to provide personal care for 17 persons aged 65 years and over. Within this registration the home may care for 5 persons who have a dementia, and one person who has a learning disability. Registration has just been approved to amend the number of people with a dementia up to 16. Crossley House is situated in Winterbourne, a village in South Gloucestershire, on the outskirts of Bristol. The accommodation is arranged over three floors in an elegant Georgian listed building surrounded by well-kept gardens. The home is close to local amenities with bus routes to nearby Yate. Ablecare Homes Ltd. own and operate the home as part of a group of four homes in the Bristol area. The other three homes are all in Westbury-on-Trym, Bristol - Rosewood House, Belvedere Lodge and Patron House. The registered manager is Mrs Jacqui Woodman. The cost of placement at the home is between £425-575 per week and is dependent upon assessed need. Additional costs are made for a range of services and these are detailed in the Homes Brochure. Prospective residents are able to find about the home by requesting a copy of this from the Home Manager. Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over 5 hours and was completed in one day. The manager was present during the inspection and participated in the process. Evidence was gained from a number of other sources namely: • • • • • • • • • Information provided by the manager in the Annual Quality Assurance Assessment (AQAA) as requested by CSCI Information taken from survey forms completed by 15 people who live in the home Information supplied by one relative Directly speaking with some of the people who live in the home Case tracking the care and support provided for a number of people residents Speaking with those care staff who were on duty at the time of the visit A tour of some parts of the home Examination of some of the homes records Observation of staff practices and interaction with the people who live in the home. The overall analysis is that the home is a good place in which to live and to work. What the service does well: The homes assessment processes and the information available about the home ensures that placement is offered to those people whose needs they can meet. People who live in this home will receive the care and support that they need because of the homes care-planning processes. Medication procedures are safe. The people who live in this home will be able to participate in a range of meaningful activities and spend their time as they wish. They are provided with well-balanced and nutritious meals. Residents can be assured that any complaints they have will be listened to and acted upon and that they will be safeguarded from harm. Crossley House is a very homely, safe, comfortable and warm home, and it is fully equipped to meet their needs of the people who live there. Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 6 The people who live in this home are cared for by skilled staff who are trained and competent to meet their care needs. Recruitment procedures are safe. The people who live in Crossley House will live in a home that is safe and run in their best interests. 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. Crossley House DS0000003318.V352829.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 Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes assessment processes and the information available about the home ensures that placement is offered to those people whose needs they can meet. EVIDENCE: The homes statement of purpose contains all the relevant information as detailed in the National Minimum Standards, but the document is in the process of being amended to reflect the changes in registration, that have just been approved. There is also information about the home in the form of a brochure, and this is given to anyone who makes enquiries about the home. Both documents are available in the home, along with the previous inspection reports. All 15 people who completed a CSCI survey form said that they had been provided with sufficient information about the home to make a decision to live there. Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 9 The home has previously demonstrated that the people who live in the home are provided with a statement of terms and conditions upon admission “Residents Contract”. Only eight people answered the question about being provided with a contract on the CSCI survey form but all eight said they had been. One person said that they did not know about a contract but added “My son deals with everything for me”. The manager visits prospective people who want to live at Crossley House, so that an assessment of their needs can be made. This visit could be made to a person’s own home or to the hospital depending upon individual circumstances. One person wrote on a CSCI survey form “My social worker brought me to look at Crossley House and told me all about it” whilst another said “I made up my own mind to come and live here”. If people are admitted from “out-of-county”, a full history is obtained from other sources. Placement at the home is not offered to any person whose needs cannot be meet. Assessments by the manager were seen on file – “Prospective Service User Needs Assessment”. People will always be invited to visit the home prior to admission, and if this is not possible, then this invite would be extended to family or friends. Placements are arranged on a month’s trial basis with a full review meeting at the end of this period with all the necessary parties present. It is possible for the trial period to be extended if someone is taking longer to settle and both parties can not decide whether the home is the right place for them. Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in this home will receive the care and support that they need because of the homes care-planning processes. Medication procedures are safe. EVIDENCE: The care planning documentation of two people who live in the home was looked at in order to determine how their care and support is identified and how their care needs are met. One of the plans was for a person who had recently been admitted to the home. The care plans were based upon a detailed assessment - Personal Preference information – this document stated that “in line with the mental capacity act 2005, this information will be used to assist staff when they need to help a resident make a decision”. These assessments formed the basis of the care plans that provide detailed guidance for the staff on how the identified needs should be met. For one person their plan recorded specific instructions on the amount of support they needed with eating and drinking. Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 11 The care plans are reviewed on a monthly basis and a record is made of any events that have occurred in the month or any changes in care needs. In each case the person had signed their care plan reviews, evidencing that they had been involved in the process. For the person who was newly admitted, the home had had a full review with the placing social worker and the notes of this meeting were on file. Of the 15 people who returned a CSCI survey form all said that “they received the care and support that they needed” and that the staff “listened and acted upon what they were asked”. Included with the care planning documentation is a moving and handling risk assessment complete with a safe system of work devised from the assessment. This means that care staff will be provided with clear guidance about how to support and aid the person they are caring for. Everyone at the home is registered with the local GP. Two CSCI comment card was returned from the surgery, one from the GP and one from a district nurse and both made positive comments regarding the home and were “satisfied with the overall care service”. People who completed CSCI survey forms stated, “ I receive the medical support that I need”. One survey form contained the comment “my mother receives the medical support she needs” The home has previously demonstrated that their medication systems are safe and that they have safe procedures in place for the ordering, receipt, storage, administration and disposal of all medicines. Either the manager or the deputy will usually give out the medications but some care staff will be responsible for administering medications after they have received training and been deemed competent to do so. The home must retain evidence of how individual staff competency has been achieved. The staff were observed going about their duties in a friendly and calm manner and responding to the residents in a familiar style. There was a lot of friendly banter between the residents and the staff, and between the residents, evidencing that the home is a good place to live. End of life care is provided when necessary, but the home would not admit anyone who is terminally ill and would require nursing care in the very near future. If a person is reaching the end of their life, the staff would work closely with the person’s GP, district nurses and relatives to ensure that appropriate care is available. Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in this home will be able to participate in a range of meaningful activities and spend their time as they wish. They are provided with well-balanced and nutritious meals. EVIDENCE: The people who live at Crossley House are able to choose whether they want to participate in any of the activities that are arranged. One person wrote in the CSCI survey form “I like to follow my own pastimes in my room”. They will be encouraged to attend local clubs and the church – “I like to go out and about by myself and also go on the outings”. Every month outside entertainment is brought in, and parties are arranged to celebrate all the festivals and birthdays. One person said “I like it when the musical entertainer visits, we have had a clothes shows and there was a good party just before Christmas”. An activities file is kept for each person, this shows who was involved in each event. Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 13 The people who live at this home are encouraged to continue with any activities outside of the home. One resident goes along to a club each week whilst another goes out to a particular past time. Those that are able to, can go out into the village as they wish and there are no restrictions made on their movements. A hairdresser visits the home on a regular basis, and several of the ladies were having their hair done at the time of the inspection- “I have always gone to the hairdressers weekly and here they come to me!” The home has an open visiting policy and visitors can come in at any reasonable time. Discussions with the manager evidenced that the home has very good relationships with the families of the residents. The home employs two cooks who cover the work, plus they have a bank cook who was working on the day of the inspection. All the people who completed a CSCI survey form said, “the meals are generally good”, and those people that were spoken with during the course of the inspection said, “ Lunch was very good”. Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that any complaints they have will be listened to and acted upon and that they will be safeguarded from harm. EVIDENCE: The homes complaints procedure is included in the homes statement of purpose and is displayed in the main reception area – it has been updated since the last inspection and has been reissued to all families and people who live in the home. Residents spoken with during the course of the inspection said they would talk to the staff if they were not happy about anything. The 15 people who completed CSCI survey forms all said that they knew who to speak to if they were unhappy about anything. One person wrote, “The staff do their very best to sort things out in the best way”. In the last 12 months the home has received just one complaint and the manager reported that this was resolved amicably. The home maintains a record of all concerns and complaints and records the action taken as an outcome – the record for the one complaint was not looked at on this occasion. CSCI have received no complaints regarding this service. Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 15 The home has policies and procedures in place to ensure that the people who live in the home are safeguarded from any forms of abuse. All staff will have or are expected to attend abuse awareness training delivered by the South Gloucestershire Council training department. The home have now obtained a copy of the South Gloucestershire procedure for reporting abuse. A copy of the homes policy about the protection of vulnerable adults (POVA) also refers to these locally agreed protocols. This is kept with all the homes other policies and procedures, and the day- to- day paperwork. Staff spoken with during the inspection demonstrated a good awareness of adult abuse issues and of their responsibility in reporting any bad practice. Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Crossley House is a very homely, safe, comfortable and warm home, and it is fully equipped to meet their needs of the people who live there. EVIDENCE: Crossley house is a listed Georgian building, set in its own grounds, and located just a short walk from the centre of the village of Winterbourne. The home is approached via a gravel driveway and there is level access into the home. The gardens to both the front and rear of the property are well kept and accessible to residents. There are areas of shade and residents can sit out on the patio on the comfortable garden furniture. Since the last inspection a new patio area has been developed outside of the conservatory complete with a water feature, ‘sensory’ plants and lighting. Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 17 The communal areas are all located on the ground floor, along with six of the bedrooms and one of the assisted bathrooms. There are two lounges, one considered to be a “quiet room”. The dining room is a conservatory to one side of the house, located next to the open-plan kitchen. The dining room has air conditioning units installed, to keep the room cool in the summer and warm in the winter. The wide staircase complete with stair lift leads from the hallway to the first floor. A second staircase from first to second floor also has a stair lift. The furniture and fittings throughout Crossley House are domestic in style and are appropriate to meet the needs of the residents. The residents were observed using all communal areas, including the large entrance hallway where seating is provided. There are a further two bathrooms, one on each of the upper floors. One toilet is located opposite both lounges. The home no longer has need for moving and handling equipment however has replaced this with a lifting cushion, should any of the people fall and need assistance in getting up. Handrails are sited in the bathrooms and toilets. One bedroom has a door guard installed as the resident likes to have their door open at all times. A call bell system is sited in all rooms, bathrooms and communal rooms. All bedrooms are for single occupation and have en-suite facilities of at least a toilet and wash hand basin. A number of rooms also have a shower. Residents are encouraged to personalise their own rooms and to bring in any items of furniture they wish. One person was keen to show off their room and said “ I have the best room in the house”. Each bedroom is fitted with a door lock and the resident can have a key if they wish. The bedroom furniture is varied throughout the home. Each bedroom has a window and the degree of opening has been limited on each. All radiators throughout the home are guarded with boxed radiator covers. The company’s maintenance team complete all repairs and redecorations and will arrange for specialist trades people where appropriate. The home was clean, tidy and well maintained and there were no odours throughout. Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in this home are cared for by skilled staff who are trained and competent to meet their care needs. Recruitment procedures are safe meaning that they will be looked after by suitable workers. EVIDENCE: The home employs a team of care staff, plus domestic and catering staff, led by the manager. Since the last inspection a deputy manager has been employed. The home does not use agency staff, but has a number of bank staff who will cover vacant shifts - this mean that the people who live here will be cared for by staff who are familiar with their needs, and are known to them. On the day of inspection there was one care assistant, the cook and a domestic plus the deputy and the manager on duty. This level of staff is appropriate to meet the needs of residents. There has been very little staff turnover since the last inspection, therefore only a few new members of staff have been recruited. The home currently has three members of staff who are trained to at least an NVQ level 2 (20 ), and two others are working towards achieving the award (33 ). The home should continue to commit to the NVQ training programme to ensure they meet the 50 target. Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 19 There have been three new members of care staff employed since the last inspection. An examination of their personnel file evidenced that the home follows safe vetting and recruitment procedures. An application form is completed and prospective employees are expected to attend for interview. Two written references, POVAfirst checks and CRB clearance are in place for each person. The home has complied with a requirement notice issued following the last inspection for their recruitment procedures to be tightened up. All new staff will complete an induction-training programme at the start of their employment, to ensure that they are aware of the homes procedures and are competent in the areas of their work. The home has introduced a new “staff induction package” that meets Skills for Care guidelines. The programme covers principles of care, person centred planning, health and safety, manual handling, fire awareness, abuse and infection control, as well as what their role entails. The manager Mrs Woodman always mentors each new employee and ensures that they work to the policies and procedures of the home. Certificates of training courses each staff member has attended, evidence that the staff group have received training in a wide range of relevant subjects. Examples include Manual Handling, Safe Medication Procedures, mental Capacity Act training, depression in older people and catheter care. A number of staff have recently attended further Dementia Awareness training in readiness for the changes in registration. Both the manager and staff referred to recent First Aid training they had attended but the certificates had not been provided yet. Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in Crossley House will live in a home that is safe and run in their best interests. EVIDENCE: The Registered Manager for the home is Jacqui Woodman. She has worked for Ablecare Homes for many years and has been the home manager at Crossley House for four years. She has already achieved the Registered Managers Award and an NVQ Level 4 in Care qualification, and has undertaken other training relevant to the care of older people and those with a dementia. Mrs Woodman was available during the inspection visit and was able to provide all of the homes records as requested. This evidences that the home has good systems in place and is well run. Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 21 Since the last inspection a deputy manager has been employed who also has many years experience in both hospital settings and care homes. Both have a “hands-on” approach and are involved in the day-to-day running of the home and care of the people who live there. Staff meetings and residents meetings are held on a regular basis and there was evidence that everyone is encouraged to make suggestions about how the run is run and what happens. The home completes a service satisfaction survey in April every year and Abelcare Homes have previously shared the results of this with CSCI. The outcome was that in general the residents were happy with the service received. The survey covered meals, choice of activities arranged, home arrangements, involvement in care planning and ability to express any concerns or complaints. The home has good systems in place to manage any monies they hold on behalf of the residents. A number of the accounts were checked against the records held and they tallied. Since the last inspection, but only most recently, formal staff supervision has fallen by the wayside. The manager openly acknowledged that this was the case and that “informal” arrangements had been in place for the last six months. Records showed that most staff had not had any supervision since June 2007. The manager must ensure that staff are appropriately supervised and written records maintained of all meetings. Staff should be supervised at least six times a year. All the necessary environmental checks were completed. There was evidence that new staff had been instructed in the homes fire safety procedures and the fire alarm system. All the health and safety testing of electrical equipment and stair lifts were up to date. The fire log showed that regular fire drills have been performed at various times of the day, and that all the staff have been included at some time or another. The manager has attended fire warden training. The home was well maintained throughout by the Ablecare Homes maintenance team. The house has listed building status. Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 3 X 3 3 X 3 Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP36 Regulation 18(2) Requirement The home must ensure that all staff have formal supervision. This should be at least six times per year. Timescale for action 28/02/08 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 OP1 Good Practice Recommendations Provide CSCI with a copy of the updated Statement of Purpose. Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Crossley House DS0000003318.V352829.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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