Care Home: Villarose

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What the care home does well There is a consistent and dedicated staff team. There is a pleasant and calm atmosphere in the home, with the service users appearing to be relaxed, content and happy.They actively promote Equality and Diversity. This is evident in the minutes from the staff meetings and in the `topic` on the agenda for peoples` supervisions (see staffing section). The provider is committed to continually improving the environmental standards for the benefit of the people who live and work at Villarose. The home is well managed and organised. The management are prepared to listen to advice and act upon any constructive suggestions made by the CSCI. What has improved since the last inspection? The pre admission process has improved, with assessments being carried out prior to admission, with sufficient and appropriate information. Service users` and staff files have been audited and are now better organised. Some very good quality environmental work has been carried out including, redecoration (inside and outside), some re-carpeting and curtains replaced throughout the home. The coordinating and provision of activities has improved, with having staff that are specifically employed to facilitate activities, outings and events. The new quality assurance-monitoring programme has had a positive and beneficial effect, with regards to people`s views, choices and ideas. What the care home could do better: Purchase and use a recognised `controlled drugs register`. This would appear to be more professional in maintaining accurate, secure and confidential records. Continue with the good level of refurbishment that is already underway. Ensure that the kitchen is refurbished to a good standard. (Environment section) Reorganise the seating arrangements in the dining room. This would help encourage socialisation, communication and promote stimulation. CARE HOMES FOR OLDER PEOPLE Villarose 256 Clifton Drive South Lytham St Annes Lancashire FY8 1NE Lead Inspector Phil McConnell Unannounced Inspection 22nd November 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 Villarose DS0000009787.V344162.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. Villarose DS0000009787.V344162.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Villarose Address 256 Clifton Drive South Lytham St Annes Lancashire FY8 1NE 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) 01253 711860 Mr Michael John Garthwaite Mrs Margaret Garthwaite Mr Michael John Garthwaite Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Villarose DS0000009787.V344162.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st September 2006 Brief Description of the Service: Villa Rose care home provides residential accommodation for up to 15 older people who do not require nursing care. The home is located in a predominantly residential area and in close proximity to the town centre and community services and resources. The home is in the main bungalow accommodation however a small number of bedrooms are located on the first floor of the building. Villa Rose is well maintained and furnished to a high standard in all communal areas of the home. Bedroom accommodation is comfortably furnished and reflects the needs and wishes of the individual occupant. A number of bedrooms provide an en-suite facility that supplements adequate communal facilities that are equipped with appropriate aids and equipment to address individual requirements. The external environment of the home provides landscaped garden areas that are easily accessible and furnished with garden furniture in the summer months. All service users are encouraged to remain as independent as possible and determine their chosen daily living pattern. Participation in community and ‘inhouse’ activity is encouraged and relatives and friends are made welcome at any time of the service users choice. The present rating of charging is between £345 and £399. Villarose DS0000009787.V344162.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information was gathered in order to assess the key standards that are identified in the National Minimum Standards for care homes for older people, including: the Annual Quality Assurance Assessment, (AQAA) which is a self assessment document completed by the manager, some surveys returned to the commission from service users and relatives and an unannounced inspection visit to the service on the 22nd of November 2007, which lasted approximately 7.5 hrs. The registered manager Michael Garthwaite was available during the inspection visit. During the visit to Villarose 4 service users’ files were examined, including the most recent person to go and live at the home and discussions took place with some of the service users throughout the day. All of the files were well organised with all relevant documentation being in place. There was the opportunity to observe the care provided to the service users and the interaction between them and the staff. Three staff files were also examined, including the last person to be employed at Villarose, with all documentation being found correct. Throughout the visit there was the opportunity to have conversations with other staff members and there was also the opportunity to speak to a visitor to the home. All of the feedback from these discussions was very positive. The homes policies, procedures and all other documentation including health and safety files and certificates were examined. (See management section). A full tour of the home was also carried out. (See environment section). What the service does well: There is a consistent and dedicated staff team. There is a pleasant and calm atmosphere in the home, with the service users appearing to be relaxed, content and happy. Villarose DS0000009787.V344162.R01.S.doc Version 5.2 Page 6 They actively promote Equality and Diversity. This is evident in the minutes from the staff meetings and in the ‘topic’ on the agenda for peoples’ supervisions (see staffing section). The provider is committed to continually improving the environmental standards for the benefit of the people who live and work at Villarose. The home is well managed and organised. The management are prepared to listen to advice and act upon any constructive suggestions made by the CSCI. 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. Villarose DS0000009787.V344162.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 Villarose DS0000009787.V344162.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 intermediate care is not provided). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes admission process is concise and thorough. This helps give the assurance that peoples’ needs will be clearly identified and determined if they can be met. EVIDENCE: Four service users’ files were examined including the most recent person to go and live at Villarose. All of the files contained relevant assessment documentation including: admission assessments, care plans, reviews of plans and up to date daily record sheets. The Annual Quality Assurance Assessment (AQAA) states, “We visit people in their own homes or hospital prior to admission to assess them. We try our best to reassure them and encourage them to visit the home before making a decision” and “we have a pre- admission care plan assessment, which we Villarose DS0000009787.V344162.R01.S.doc Version 5.2 Page 9 discuss with the resident and their family and we provide all residents with a contract, which clearly shows fees and any extra charges, this is fully explained to them and their families”. It was evident that a thorough and robust pre-admission process was in place and in discussion with the manager it was clear that the process is successfully used for all new service users who to come to live at Villarose. One person commented, “senior staff visited me in hospital. My son visited the home twice and I visited the home before coming in” and a relative wrote, “The Villarose gave us all the information we required”. Villarose DS0000009787.V344162.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ care plans are thoroughly detailed, with specific health care needs clearly identified. It is evident that peoples’ assessed needs are being appropriately provided and people are treated with respect and dignity. EVIDENCE: Four service users’ care plans were examined and they were well detailed, containing thorough and relevant information. The care plans are developed from the initial admission assessment. This gives the carers clear and concise guidance in how to appropriately provide peoples’ assessed needs. Care plans are reviewed on a monthly basis. Peoples’ files also contained up to date and appropriate daily diary notes. The AQAA states, “Being a small home, with mainly full time staff that have been with us for some time, means we all have a good knowledge of our Villarose DS0000009787.V344162.R01.S.doc Version 5.2 Page 11 residents’ needs” and “We ensure that the residents health care needs are met by consulting with other health care professionals”. Information was available with regard to peoples’ specific health care needs and there was evidence that, hospital appointments, GP’s appointments and other treatments and consultations with other health professionals had been carried out. One GP wrote, “I am more than happy with the care that Villarose provide to my patients” and some comments from a community matron were, “I have always been shown to patients own private rooms for consultation” and “never had any concerns about the care in the home, if a GP visit is required or appointment of any kind e.g. dentist or chiropodist etc, this is swiftly dealt with. This home offers a good all round care setting”. The comments from relatives were all positive with regards to health care needs including, “The Villarose helped my Mother to attend all her medical appointments” and “they show sensitivity to the individual in meeting their needs and provide tremendous care and kindness”. There is a policy in place for staff to adhere to the procedures for the receipt, recording, storage, handling, administration and disposal of medicines. There are ‘declaration of wishes’ forms available, which give clear instructions of what a person’s wishes are, with regards to the level of assistance needed (if any) with their medication. One person said, “I used to worry about mums medication, but it’s all sorted here, it’s great”. The medicines are appropriately stored in a safe, secure and unobtrusive cupboard. The medicine administration records (MAR) were observed and were found to be accurate with medication being correctly administered. It was recommended to the manager that a ‘Controlled Drugs Register’ be purchased; this would help maintain correct, secure and professional records for any controlled medicines that are administered. Members of the staff team were observed demonstrating a caring, sensitive, dignified and respectful approach, with service users responding positively and it was evident that good relationships existed between service users and the care staff. Some of the comments received were, “whenever I visit I see the staff as extremely caring and competent” “all of the staff are very caring” and one relative said, “I live a long distance from here, but I don’t have any more sleepless nights since my mum came to live here. I know she is treated properly and well looked after”. Villarose DS0000009787.V344162.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. There are appropriate, recreational and leisure activities available, demonstrating that people are positively motivated and stimulated. EVIDENCE: The home employs an activities coordinator and in observation and in other evidence gathered it was apparent that a varied number of activities take place on a daily basis within the home to help motivate and stimulate people. During the inspection visit a group of service users were observed being actively involved in making Christmas ornaments/decorations for the forthcoming Christmas Fair. The home has a monthly ‘special event’ when a trip out to a place of interest is arranged. The activities and any forthcoming events are prominently displayed in many areas of the home. Villarose DS0000009787.V344162.R01.S.doc Version 5.2 Page 13 People were quite excited about the Christmas Fair and in discussion with some people it was apparent that the activities and other recreational events available are very much appreciated. The AQAA document states, “The staff are also focusing on making sure everyone has an opportunity and are trying hard to engage those who would not normally choose to participate”. This helps to demonstrate that inclusion; equality and involvement are positively and actively promoted. It was also evident that the provider is consistently seeking to find out what peoples’ interests are and if they are being provided. The provider is now using an internal ‘service user questionnaire’, which asks a question about the maintaining and provision of peoples hobbies and interests. This also helps to show that people are given the opportunity to voice their opinions and make choices in their daily lives. The home has an open house policy with visitors to the home being made welcome and service users are encouraged to maintain relationships with their families and friends. One relative wrote, “I am always welcomed warmly and made to feel at home”. One person said, “Whenever I visit I am automatically invited to have a meal with my mum, it’s fantastic”. During the inspection visit there was the opportunity to observe service users meeting visitors in the privacy of their own rooms. There was a choice of menus available, which were seen to be nutritious, varied and appetising. A ‘kitchen book’ is kept in the kitchen containing a record of meals being provided, with the homes cook having control of all the food ordering. There was the opportunity to have lunch in the home and the meal was good and well presented. Some of the comments received were, “The meals are excellent” “the cooking is just like home cooking” “the food is marvellous, suits me down to the ground” and “the meals are always very good”. It was suggested to the manager that the present layout of the dining room, doesn’t necessarily promote socialisation or communication. An assurance was given that people will be consulted with regard to the possible repositioning of the dining room tables. Villarose DS0000009787.V344162.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. Satisfactory policies and procedures are in place, helping to demonstrate that vulnerable people are protected and safeguarded from abuse. EVIDENCE: A comprehensive complaints policy and procedures is in place regarding the safeguarding and protection of vulnerable adults. The questionnaires that had been returned to the commission indicated that people are fully aware of the complaints procedure and how to complain if they needed to. There is a clear notice displayed in the entrance hall, explaining how anyone can make a complaint. Some of the comments received by the commission (CSCI) were, “I have never needed to complain, but I would know what to do if I had a complaint” and “I was given some information about making a complaint, when my mum moved in”. Villarose DS0000009787.V344162.R01.S.doc Version 5.2 Page 15 A comprehensive complaints policy and procedure was in place regarding the safeguarding and protection of vulnerable adults. No complaints have been received since the last inspection. There was a thorough policy in place to deal with a suspicion or allegation of abuse and the AQAA states, “This year we have acted upon suggestions from staff and provided paid ‘off-the-job’ training for abuse awareness”. There was evidence to show that all of the present staff have received this training. This demonstrates that the provider is committed to ensuring that service users are protected, with care staff being appropriately trained and aware of any of the potential abuse situations can affect vulnerable people. Villarose DS0000009787.V344162.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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environmental standards are of a good quality, with the management being committed to maintaining a safe and well-maintained environment for both service users and staff. EVIDENCE: A full tour of the home was completed and throughout it was found to be of a good standard, it was clean, homely and fresh smelling. On the day of the inspection visit a new carpet was being fitted to one of the homes’ lounges. This demonstrates that the provider is proactive in maintaining the good environmental standards that are already in place. Since the last inspection visit a number of positive changes have taken place including, the painting of the exterior of the building, some re-carpeting, new Villarose DS0000009787.V344162.R01.S.doc Version 5.2 Page 17 curtains, and some of the bedrooms had been decorated to a very good standard. It was stated, “It is planned to redecorate all of the bedrooms”. Some of the bedroom carpets are in need of being replaced; again an assurance was given that new carpets are planned. Peoples’ bedrooms contained personal belongings, such as televisions, photographs, ornaments and some of their own furniture items, demonstrating that people are encouraged to bring their own personal possessions into the home, in order for it to be familiar and as comfortable as possible. The homes laundry is only small but well organised and clean, with sufficient machines to meet peoples’ needs. The kitchen was clean, hygienic, organised and well equipped to meet the homes needs. However, some of the kitchen units and worktops are looking a little old fashioned and worn out. This was discussed with the manager and it was commented, “we are shortly going to refurbish and update the kitchen”. Some of the comments received were, “It’s a very good home, with a happy atmosphere” “the home is immaculate and well decorated” and “the home is always looking to improve its standards”. There was appropriate specialist equipment observed around the home, such as lifting hoists, stair lift, walking frames, bath seats/shower chairs and wheelchairs, thereby helping to ensure that individual needs are catered for, whilst independence is promoted. Overall the environmental standard is generally good, with the changes that have taken place since the last inspection being of a good standard. In discussion with the manager, it is envisaged that more improvements will happen in the near future. Villarose DS0000009787.V344162.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 excellent. This judgement has been made using available evidence including a visit to this service. Villarose have a dedicated, consistent and well-trained staff team. This gives the assurance that vulnerable people are well cared for and supported by experienced and skilled people. EVIDENCE: The staffing levels for the Villarose were examined and they were found to be adequate and satisfactory. There has been a consistent staff team at Villarose for sometime now, this helps give the service users and their relatives confidence and assurance. As already mentioned the staff demonstrated a caring, sensitive, dignified and respectful approach, with service users responding positively and it was evident that good relationships existed between service users and the care staff. It is also apparent that trusting relationships exist with service users relatives. There is a thorough recruitment process in place, with staff files containing evidence that Criminal Record Bureau (CRB) checks had been carried out and staff are only employed on the satisfactory completion of these checks with two independent satisfactory references being obtained (this was a previous Villarose DS0000009787.V344162.R01.S.doc Version 5.2 Page 19 requirement). It was also observed that all overseas staff have Home Office clearance to work in the UK. This helps to demonstrate that vulnerable people are protected and safeguarded, by having a robust recruitment process. Staff files contained information with regards to the experience, skills and training that staff have received with a full and thorough mandatory-induction programme being in place. As already mentioned all of the staff team have received ‘Abuse awareness’ training and other relevant training is being provided including, confusion and dementia awareness There was evidence of other relevant training being provided including, Infection control, Dementia Awareness and Avoidance of Abuse of the Elderly. The national vocational qualification in care (NVQ) training programme is ongoing and there was evidence that the provider is committed to ensuring that this NVQ training is accessed for all staff, with over 90 of staff having achieved this award. All of the feedback from relatives and people living at the home regarding the staff was positive and complimentary including, “the staff are always available” “lovely staff who were there when I was in (respite) the home” “the staff team are fully qualified and whenever I visit I see them as extremely caring and competent” and “the staff give comprehensive and loving care to the residents, meeting their needs with a pleasant and happy demeanour. Individual staff supervisions are held on an 8 weekly basis and annual appraisals are also carried out. The provider has recently introduced a ‘topic’ theme for each person’s supervision. It was observed that the theme for November was ‘Equality and Diversity’. Staff members are informed of the forthcoming topics and are asked relevant prior questions, in order to promote positive and constructive discussions. Villarose DS0000009787.V344162.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, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, with the best interests of the service users being paramount. EVIDENCE: The registered manager has over 18 years of experience in the care profession and has been the registered manager at Villarose for 17 years. He is adequately qualified, having achieved the national vocational qualification in management at level 4, (NVQ) and he has recently received training in the ‘prevention of abuse’ and care of the dying and bereaved’. Villarose DS0000009787.V344162.R01.S.doc Version 5.2 Page 21 The AQAA states, “The home has an enviable reputation in the area and is highly thought of by visiting health professionals”. Some comments received were, “the home is very well managed” and “the home owner goes beyond the call of duty”. The home’s policies and procedures were examined and they were found to be up to date (reviewed February 2007) and of a good quality. The home continues to maintain the investors in people award; this is an external quality assurance-monitoring organisation. The management have shown commitment and dedication in getting the opinions and ideas from service users and staff. This has been by way of regular team meetings, service user meetings (minutes of meeting in large print) and by implementing an internal ‘quality assurance’ system, using easy format, concise and thorough questionnaires. “This is to seek the views of staff, residents and relatives”. The questionnaires were available for observation and it is clear that this tool is taken seriously, with evidence available to demonstrate that the findings from the questionnaires had been acted upon. The manager said, “I am so pleased with this quality assurance programme, it confirms what we do and helps you to really focus”. There was documented evidence to show that all staff have received mandatory training in the relevant courses, with refresher courses being made available when needed. There was an up to date health and safety policy, with comprehensive, individual and corporate risk assessments, promoting the health, safety and independence of service users. All health and safety inspection certificates were in place and up to date, including: gas safety certificate, electric check certificate, fire extinguisher checks, PAT (portable appliance testing), emergency lighting certificate and hoists and stair lift inspection certificates. There was sufficient evidence to demonstrate that the health and safety of people who live and work at Villarose is promoted as much as possible, to help ensure that a safe and healthy environment is maintained. There were procedures in place, regarding service users’ finances, with appropriate and adequate records being kept, helping to ensure that people’s finances are safeguarded. Villarose DS0000009787.V344162.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 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 4 28 4 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 Villarose DS0000009787.V344162.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. 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 OP9 Good Practice Recommendations Controlled drugs handling and recording should be reviewed to ensure no mishandling could occur. It would be seen to be good practice to use a recognised controlled drugs register. Villarose DS0000009787.V344162.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Villarose DS0000009787.V344162.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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