Care Home: Winscombe

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What the care home does well The home has endeavoured to comply with the requirements made on the last inspection. Observations of care staff interactions with service users indicated that service users were treated with dignity and respect. It was also observed that great care was taken in respect of the service users personal belongings and standards of cleanliness in bedrooms ensured service users lived in a safe, well-maintained environment. The home has a stable work force, which should benefit the service users and this is best reflected in the care given to service users. Care workers spoken to were very pleased of their record that they have no service user in their care suffering from pressure sores. The home has demonstrated that service users views are taken into account and changes made to the menu and activities as a result. What has improved since the last inspection? All requirements issued on the last inspection have been actioned within the given timescales The home continues to be proactive in meeting the training needs of the care workers in order that seamless care can be offered to the residents. A number of staff has undertaken the Equality and diversity course as part of their NVQ learning and the home has employed a training co-ordinator to ensure all staff training needs are identified and met. The home continues to refurbish bedrooms and replace worn carpets as per their annual refurbishment plan. What the care home could do better: The home continues to provide a good standard of care to the service users living at the home. CARE HOMES FOR OLDER PEOPLE Winscombe Furze Hill Kingswood Surrey KT20 6EP Lead Inspector Mavis Clahar Unannounced Inspection 10th October 2007 10:10 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 Winscombe DS0000013370.V352824.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. Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Winscombe Address Furze Hill Kingswood Surrey KT20 6EP 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) 01737 362442 01737 362458 winscombeALL@bupa.com / rajakac@bupa.com www.bupa.com BUPA Care Homes (BNH) Ltd Mrs Chrysanthy Rajakarier Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing only - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 30. Date of last inspection 12th June 2006 Brief Description of the Service: Winscombe is a purpose built single storey care home in secluded surroundings with landscape gardens and a central courtyard. The home is situated in a convenient location on the outskirts of Kingswood Village and provides accommodation and care for up to thirty older people. The three lounges and centrally located dining room are within easy reach of service users bedrooms. Each bedroom is single occupancy with its own wash hand basin. The home has ample bathroom and toilet facilities some of which are assisted. Car parking facilities are provided to the front of the building and the home is close to the train station and bus route. Fees at this home are in the range of £883.24 to £1029.62 per week. Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit, which forms part of the home’s key inspection to be undertaken by the Commission for Social Care Inspection (CSCI) was carried out by Mrs Mavis Clahar on the 10th October 2007 and lasted for six hours and forty minutes commencing at 10:10 hours and concluding at 16:50. The majority of the service users spoken to were able to express their thoughts and feelings about the care they receive. The information contained in this report was gathered mainly from observation by the inspector, speaking with a number of service users, and with care staff. Further information was gathered from records kept at the home, from the Annual Quality Assurance Assessment (AQAA) completed by the manager and from the pre inspection questionnaire returned to CSCI by the relatives, service users and staff working at the home. The first part of the inspection was spent discussing and agreeing the inspection process with the manager, followed by a tour of the home, which included time spent in discussion with service users, care workers and the Chef. The manager and staff are aware of the Laws regarding equality and diversity and this was reflected in the staff mix. All service users in this home are Caucasian and reflect the population of the area in which the home is situated. All records sampled were up to date with care plans being signed by the service users or by relatives. No requirement or recommendation of good practice was issued on this visit. The final part of the inspection was spent giving feedback to the manager about the findings of this visit. The inspector would like to thank all the service users and care staff that made the visit so productive and pleasant on the day. Thanks also to all the relatives, service users and care workers who took time to complete the Commission for Social Care Inspection (CSCI) questionnaire. Your views on the home are highly valued and are incorporated into the report. What the service does well: The home has endeavoured to comply with the requirements made on the last inspection. Observations of care staff interactions with service users indicated that service users were treated with dignity and respect. It was also observed that great Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 6 care was taken in respect of the service users personal belongings and standards of cleanliness in bedrooms ensured service users lived in a safe, well-maintained environment. The home has a stable work force, which should benefit the service users and this is best reflected in the care given to service users. Care workers spoken to were very pleased of their record that they have no service user in their care suffering from pressure sores. The home has demonstrated that service users views are taken into account and changes made to the menu and activities as a result. What has improved since the last inspection? What they could do better: The home continues to provide a good standard of care to the service users living at the home. Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 7 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. Winscombe DS0000013370.V352824.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 Winscombe DS0000013370.V352824.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): 3.6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their relatives have the information needed to choose a home, which will meet their needs and service users are being assessed to ensure the home is capable to meet the needs of the service users prior to being admitted into the home. EVIDENCE: Review of service users documents and identified policies demonstrated the home has a policy and procedure on admission and discharge of service users. Within the admission policy all service users must have an assessment prior to being admitted into the home. The manager and deputy manager who are both trained in the principles of assessment of service users’ needs based on what the care the home says it will provide carries out all pre admission assessments of service users prior to them being admitted into the home. Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 10 Review of a random sample of service user’s files including one recently admitted service user, demonstrated that pre admission assessments are being carried out. This home does not provide intermediate care. Winscombe DS0000013370.V352824.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. The home has a good and clear care plan in place for service users, which also includes appropriate risks assessments. This forms the basis for care based on the agreed care needs of the service users and demonstrated that health and personal care needs were met. Care staff receives training to meet the assessed care needs of the service users ensuring that competent staff supports service users and their health and care needs are met. The home’s medication policy on receiving, storing and administering of medication was in place and being adhered to thereby ensuring the safety and protection of the service users. Care workers treated service users with respect and maintain their dignity and privacy when delivering personal care. EVIDENCE: Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 12 The randomly selected care plans were clear and easy to read, identifying potential and actual risks to service users and detailing how these risks would be managed. The daily work sheet along with discussion with service users and care workers demonstrated that service users care needs are fully met. The service user or relative and the manager sign all care plans reviewed. Information contained in the relatives and service users response to CSCI pre inspection questionnaire supported this. All service users are registered with a local General Practitioner (GP) of their choice and visits are recorded, with access to specialist healthcare professionals through their GP practice as required. Service users are offered a six weekly access to chiropody service. It was noted that the home had a record of no pressure sores developing on service users in the home. On the day of inspection we observed service user being nursed entirely in bed and noted that no sings of pressure sores were visible according to the care notes. In discussion with the registered nurse and care worker they were extremely proud of the high standard of care they provided to this service user and to all service users in the home. Care staff identified as capable to administer medication are requested to leave a sample of their signature, which is dated in the medication trolley. All service users have a recent photograph included in their medication record to reduce the risk of mistakes happening during medication administration. Some service users were assessed as capable to self medicate, and the Registered Nurse was able to show documented proof of this and to discuss the management of this aspect of medication care. This aspect of medication management was supported in discussion with the manager. Medication records were checked and found to be correct as documented on the Medication Administration Record (MAR) sheet. Eight relatives responded to the CSCI questionnaires and both stated they were happy with the care given to the relatives, and that the staff are always polite to them and they were free to visit any part of the home their relative was using. We observed that care workers did wear name badges to enable visitors and service users with memory impairment to be sure of whom they are speaking with. We observed Service users being treated in a friendly but respectful manner by care workers. It was noted that care workers communicated amongst themselves and with the manager and with the service users in English. In discussion with a number of service users we were told that they are treated with respect and dignity, and that they are able to make their own choice. One service user told us “I am very happy here. Everything is so nice. I have my own room; I can have as much privacy as I want. We have good Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 13 staff here; they do not ill treat me. I choose my own clothing every day. I did not see the reason why I had to complete your questionnaire but I did it. Any issues I have I speak to the manager and it is sorted.” Another service user told us “ I can manage to do everything for myself. They are always asking if there is anything I want, but I can manage on my own I just need the company.” Winscombe DS0000013370.V352824.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users lifestyles matched their needs and preferences and where possible they are able to maintain contact with family, friends and the local community. Service users are able to make choices in accordance with their abilities and were provided with a balanced diet in pleasant surroundings and in an unhurried way. EVIDENCE: The home employs two activity-co-ordinators who provides a range of activities based on the individual assessed and agreed needs of the service users. This activity can be one to one such as reading services, or in groups as observed on the day of the inspection. Activities includes reflection of the past, current affairs, painting/drawing, crosswords quizzes and trips to the garden centre and gentle stretching exercises. It was noted that care workers were also involved in the exercises with their service users. We were told the home has good contact with religious denominations and Holy Communion is Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 15 provided for all service users who would like to participate. The home respects those service users who wish not to participate. .The Church of England (C/E) Vicar visits on a monthly basis and the Roman Catholic Priest visits as needed. Service users told us visiting is open, and that they can entertain their guests in their bedrooms in private or in the spacious communal areas of the home. The information contained in the AQAA and in the relatives response in the CSCI pre inspection questionnaires supported this statement. We were told the home has two lovely cats, and some service users said they derived great comfort in stroking them. Three of the service users spoken to said they had choice in their clothing and sometimes they receive help from their key worker. On the day of inspection all service users were dressed appropriately for the weather. We were told the Chef who has been at the home for a long time operates from a four-week menu and there is always a choice of two hot meals per day at mid-day, or salad at mid-day or the service user can choose their own food e.g. omelette etc. One service user told us the Chef is very good and she comes around every day to make sure we are satisfied with our food. This service user further told us they like a special vegetable and the Chef always prepares it for them. The evening meal is always soup followed by hot meal or sandwiches filled with service users choice. There were ample amount of fresh fruit, available in the home, and the Manager following consultation with service users and relatives told us they have introduced “Food bite” which is a means of always having healthy snacks available for service users between the hours of 17:30 to midnight should service user feel they need something to eat. Service users spoken to regarding “food bite” told us this was a splendid idea as it was along time from supper in the evening to breakfast the next morning to be without access to food. The inspector did not sample the lunch, but service users said the food was very good, tasty and the right amount. The inspector observed the presentation of the food was done in a way to stimulate appetite. Lunch was served in the dinning room unless a service user requested to have their meals in their bedrooms. We observed care workers interacting in a friendly but dignified manner with service users during the lunch time, sitting down beside service users and speaking to them whilst helping them with their lunches. Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 16 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 a satisfactory complaints policy and procedure and training in place that evidenced that service users and relatives concerns are listened to and acted upon. Robust Safeguarding adults’ policies are in place to protect the service users from abuse. EVIDENCE: CSCI received no complaints about the home. Two substantiated complaints were logged at the home, and were all dealt with satisfactorily according to the home’s records; and within the home’s time scale for dealing with complaints. The manager told us that she is in touch with service users on a daily basis and issues raised are dealt with immediately; this reduces the incidents of formal complaints. Service users spoken to said they have no need to complain, as they are able to discuss everything with the manager. The home has a complaints procedure and policy, which is fully adhered to. It was noted that the home received a large number of compliments from relatives of service users commending the staff on their kindness and understanding and for the high quality of work they perform. One relative commented “The friendly atmosphere as one enters Winscombe is immediately apparent as is the care given by staff to residents. We put huge trust (as relatives) in the Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 17 staff of nursing homes and so it is a great comfort to know that expectations are carried out thoroughly”. In discussion with care workers, it was apparent they are aware of the homes’ policy and procedure on Safeguarding Adults and felt secure in the knowledge that if they had to use the whistle blowing procedure the manager and the Owners of the home would support them. During discussion with care workers it became apparent they had a sound knowledge on Equality and Diversity issues relating to the service users they were responsible for. A random sample of care workers training record demonstrated that care workers are being trained to undertake the duties of meeting the service users assessed needs, thereby protecting them from abuse. We were shown documented proof that both the manager and deputy manager have been offered a place on the Surrey multi-Agency course on Safeguarding Adults, due to commence later this month. Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 18 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. The physical design and layout of the home enables service users to live in a safe, well- maintained and comfortable environment, which encourages independence, and protect their privacy and dignity. EVIDENCE: The manager told us that the management and staff encourage service users to see the home as their own home and this was supported during discussions with service users. The home presents as a comfortable, attractive home, which has all the specialist adaptations, needed to meet the service users needs. The home has attractive gardens, which is divided into a central courtyard garden and small areas of garden outside most patio doors and a larger Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 19 garden. All the gardens are well maintained and there is good access to the gardens from various parts of the home. Some service users told the inspectors that they try to go out daily weather permitting to enjoy the gardens. One service user we were told is the head gardener and in discussion with this service user, we were told gardening is therapeutic and that they enjoy the garden. We noted that adverse weather would not stop service users enjoying the garden, as the windows are low enough to allow service users to view the gardens from their armchairs, specially the courtyard style garden and the personal garden by the patio doors of service users bedrooms. It was noted that service users were able to personalise their bedrooms with small items of furniture, paintings on the wall and many family photographs. Generally, the home presents as clean, safe, pleasant, hygienic and tidy and free from offensive odours. Random review of care workers training record demonstrated they have had training in infection control and this was evident in the storage of waste. Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 20 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. Staff in the home are trained, skilled and in sufficient numbers to fulfil the aims of the home and meet the changing needs of the service users. EVIDENCE: The staff rota demonstrated the number and grade of staff on duty to provide care and attention to service users for any twenty-four period was adequate to meet the assessed care needs of the service users. The home has a programme of planned training in place and we were told all members of staff have an individual training record this was verified by the randomly reviewed staff folder audited. Over 50 of care workers have obtained the National Vocation Qualification at Level 2 (NVQ L2). The manager has recently commenced the Registered Managers Award. Care workers are encouraged and enabled to undertake developmental training as well as the mandatory training. . All newly appointed staff undertakes an induction programme as recorded and documented in their personal files. The home ensures that staff undertakes the mandatory training with yearly updates as necessary to maintain their competency to fulfil their duties. This was evidenced through discussion with the manager and care workers and from review of care workers training records. The home has recently employed a Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 21 training co-ordinator, who is based at the home. The co-ordinator’s role is to discuss training and developmental needs with individual care workers, and to provide the necessary training to enable care workers to fulfil their roles and that of the home in providing a high quality of care for the service users. It was noted that staff turnover at the home is relatively low. All care workers are Criminal Records Bureau, (CRB) and Protection of Vulnerable Adults (POVA) checked prior to commencing employment, and two written satisfactory references are obtained. Care workers are in receipt of terms and conditions of employment as evidenced in their randomly selected files. We were told that supervision records were up to date and this was verified during random sampling of care workers files. In discussion with care workers they were able to give examples of how the home applied equality and diversity to the different needs and wishes of the service users in their care, and also within the diverse staff group. Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 22 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. The manager has the experience to run the home and works to continuously improve services and provide an increased quality of life for the service users. There is a strong ethos of being transparent and open in all areas of running the home. The views of service users and their relatives are actively sought in the running of the home Service users financial interests are safeguarded. The service provides training on health and safety issues for all staff and service users are involved in the running of the home. Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager has demonstrated that she has kept herself updated on issues relating to care of the service users and staff in her charge. She is currently undertaking the Registered Managers Award. In discussion with the manager, it was evident she was knowledgeable about the training needs of the care workers to meet these identified needs. There are clear lines of accountability within the home, each member of staff spoken to on the day of inspection aware of their role and responsibilities. Regular residents meetings are arranged and minutes of the meetings are passed to the owners who will action requests as soon as possible. The home does not become involved in service users finance. Review of documented records demonstrated that health and safety checks are routinely carried out at the home. All equipment examined on the day was properly maintained. Records indicated that fire drills, fire alarm, water temperature fridge and freezer recordings were regularly checked. Random sample of care workers’ training files demonstrated that up to date and relevant training were carried out by care workers to protect service users’ health, welfare and safety. In discussion with care workers they discussed their understanding and implementation of appropriate procedures to safeguard service users. Further more they spoke about their understanding of promoting safe working practices based on their health and safety training. Throughout the service there is a highly evolved understanding of the equality and diversity needs of the individual service users. Care workers are confident in delivering high quality outcomes for service users in the areas of age, sexuality, gender, disability and belief. Although the care workers are knowledgeable about issues relating to race and equality and diversity, they are not able at the moment to put this knowledge into practice with the service users, as the current service users are all Caucasians. Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 24 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 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 25 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 Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Winscombe DS0000013370.V352824.R01.S.doc Version 5.2 Page 27 - 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. 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