Inspection on 11/12/07 for 16 Pendean Court

This is the latest available inspection report for this service, carried out on 11th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

16 Pendean Court 21/03/06

16 Pendean Court 15/02/05

16 Pendean Court 08/09/04

16 Pendean Court 03/03/04

Similar services:

5 Seafield Road

Honeybourne House

Longrun House

Bodley Community Care Support Centre

Thomas Pocklington Trust

Chantry Gardens

Penkelly House

25-27a Alexandra Road

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 16 Pendean Court 16 Pendean Court Liskeard Cornwall PL14 6DZ Lead Inspector Jane Gurnell Unannounced Inspection 11th December 2007 10:30 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 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 16 Pendean Court DS0000009208.V352872.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 Adults 18-65. 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. 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 16 Pendean Court Address 16 Pendean Court Liskeard Cornwall PL14 6DZ 01579 340201 01579 344410 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Royal National Institute for Deaf People Ms Angela Nicholls Care Home 8 Category(ies) of Sensory impairment (8) registration, with number of places 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Some service users may have an additional Physical Disability (PD) or Learning Disability (LD) 2nd August 2006 Date of last inspection Brief Description of the Service: The Royal National Institute For Deaf People are registered in respect of Pendean Court to provide accommodation and personal care for up to 8 adults with a sensory impairment who may also have a learning disability or a physical disability. Pendean Court is a detached building with well-maintained grounds, situated in a residential area of Liskeard. The home is close to local shops, community facilities and public transport. The care home is purpose built with all the bedrooms and shared communal facilities provided on the ground floor. The home provides level access to assist people that may have a physical disability and specialist aids and adaptations are provided throughout the building. A vibrating pager system and flashing lights provide visual alarms for fire precautions and doorbells, minicom telephone systems, mobility aids, hoists and adjustable sinks in bedrooms are provided. The landlord of the building is Habinteg Housing Association and a programme of general maintenance is provided. The weekly fees for this service commence at £700 and are calculated on an individual basis depending upon the each person’s support needs. Information relating to the services provided by Pendean Court can be obtained directly from the home. 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and undertaken on Tuesday 11th December from 10:30am to 15:30 pm. Ms Angela Nicholls, the Registered Manager, was present and she and her staff team assisted the inspector throughout. All 6 people living in the home were spoken to as were the staff on duty. A tour of the building was made and records relating to the support needs of two people were examined, as were the personnel files for 2 staff members and the results of the home’s formal consultation with the people living in the home, their families and others involved in their support such as social workers. Prior to the inspection an Annual Quality Assurance Assessment had been completed which allows the Registered Manager to describe what the home does well, what has improved over the past 12 months and the areas for improvement that have been identified. This assessment was comprehensively completed and provided clear information about the home and the future development plans. What the service does well: The house is comfortable, warm and clean and has equipment to help people to live as independently as possible. There is plenty of good food and people can chose what they would like to eat. The people have enough things to do to be happy. They can go to college. There are always enough staff to help. The people get all the help they need to learn how to do new things. Each person can have their room just as they want it. 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 6 The staff know how to help people and the staff do their best. If someone has a problem it is easy to get help. The staff are safe to be with. If you want to live there the staff will tell you about what it is like. The staff are good at helping people to move in and be happy. What has improved since the last inspection? What they could do better: The people who live at Pendean Court are happy and the staff are good at helping people. We have not asked for anything to be made better. 16 Pendean Court DS0000009208.V352872.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. 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard 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 excellent. This judgement has been made using available evidence including a visit to this service. People who may use the service and their representatives have the information needed to choose a home which will meet their needs. EVIDENCE: There are currently six people living at Pendean Court and although the home is registered for up to eight people the Registered Manager confirmed that due to the recent changes in the home to improve the facilities there will be a maximum of seven people living at the home. There is a comprehensive pre-admission process. The Registered Manager meets with the person to ascertain their support needs and their expectations and to provide them with information about Pendean Court; the service user guide, the document describing the home, is specifically designed for each person using symbols and pictures depending on their communication needs. They are then invited to the home to meet the other people living there and are able to visit as often as they feel necessary to make a decision about the suitability of the home. During this process an assessment is undertaken that not only includes their specific personnel, physical and communication support needs, but also their preferences with regards to their educational, leisure and social activities as well as their religion and culture. 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 10 Consideration also is given to the needs of those currently living in the home. The Registered Manager confirmed that the Organisation would not admit anybody new to the home if that would cause distress to those already living there. The files of two people currently living at the home were examined and both of these contained a tenancy agreement in an easy read, pictorial format. The home must be commended for it’s comprehensive and careful admission procedure as well as their commitment to provide improved facilities rather than maximising income. 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are involved in decisions about their lives, and play an active role in planning the care and support they receive. Confidentiality is respected. EVIDENCE: Discussions with the people living in the home and the staff confirmed that people are actively consulted and enabled to make choices and decisions about their lives. People said they were happy at Pendean Court. Staff on duty were fully aware of the needs of the people living in the home and these were described in detail in each person’s support plan ensuring that the support provided by staff is done so in a consistent manner. Each person had a description of their preferred daily routine that provided a clear structure to their day as this had been recognised through discussion and assessment as being important to them. People are supported to take risks that have been carefully assessed: the risk assessments were thorough and clear. 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 12 Communication boards were used in bedrooms as well as communal areas and these gave a pictorial timetable of the day’s and week’s events. People had access to pictures and symbols for everyday activities and emotions that supported their communication with staff. The attitude and approach of the staff team promoted independence and empowered people to make decisions about lifestyles and daily routines. Person centred plans have been developed which encouraged people to share their wishes and preferences with regard to how they wished to live their lives. Each person was offered the support of a named keyworker, a member of the staff team with specific responsibilities towards supporting the person to identify what was important to them, such as relationships, education and leisure activities, and who also supported the person to discuss issues that caused them anxiety or which they found difficult to deal with. Each person had their own bank account and two people were independent with their finances receiving their personal allowance each week to spend as they wished. Staff supported the other four people to manage their finances and their money was held in the home’s office for safekeeping. Individual records relating to this money were very clear and were audited each week by the Registered Manager to ensure their accuracy. People were expected to participate in the day-to-day running of the home, including housework and laundry, menu planning and shopping, and meal preparation and this was evident on the day of the inspection. 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People can learn life skills, attend educational placements, participate in any community and leisure activities, choose their own daily routines and enjoy a healthy diet of their choice. EVIDENCE: Discussions with the people living in the home as well as staff showed that people are enabled to live as full a life as they wish to with opportunities for personal development. People are encouraged to carry out all the domestic tasks in the home and participate in leisure activities of their choice including holidays- the organisation gives each person £500 for an annual holiday. All activities were planned on an individual basis and through weekly residents meetings each person was encouraged to plan what they would like to do the forthcoming week as well as planning their meals. Activities included trips to local places of interest including the town centre, hydrotherapy pool, yoga 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 14 classes, clubs and discos, gardening and attending various educational placements. In-house numeracy and literacy training is provided by the Registered Manager, who is a trained teacher for adults, and another senior member of staff who is undertaking a training course to become a teacher for adults with learning disabilities. This training was specifically related to support each person to be more independent with community activities. People were encouraged and enabled to continue with their education at local colleges. One person is undertaking a cookery course at the local college and another is about to take a first aid course. All those living in the home are invited to join in the training organised for the staff, for example everyone undertook the food hygiene course. A computer, scanner, photocopier and printer were available in the main lounge for people to use. One person described that the organisation was going to fit a phone line in her bedroom so that she had access to the Internet. Each person is invited at attend a residents meeting each Thursday to discuss the forthcoming weeks’ events and to plan the menu as well as to decide which take-away meal to have on Saturday evening: notes of these meetings were kept and used to review the overall quality of the support and services being provided. Healthy eating guidance had been provided in an easy read format to help people make choices about the food they eat. People are involved with shopping and preparing meals, drinks and snacks. On the day the visit one person had been into town to buy fruit for the lunchtime dessert. People were looking forward to Christmas and the organisation had given each person £30 to enjoy a meal out (staff had each been given £15 towards the cost of a meal). Each person had a key to their bedroom with staff only having access with the person’s permission or for reasons of health and safety and to protect their well being. Contact with relatives and friends was supported. Those relatives who returned a survey said that their relatives were being well supported and visits to Pendean Court as well as the parents’ own home were encouraged. The home has the use of two vehicles and no charge is made for their use. 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Pendean Court receive support in the way, and at the time, that they want and need. Health care needs are addressed as soon as they are identified. EVIDENCE: The support plans for two people were examined and these provided very clear descriptions of personal, emotional and health care needs and the goals and aims of this support. This clarity is important to ensure that the support team are fully aware of each person’s specific needs and can respond in a consistent manner. The Registered Manager has provided each person living in the home with a copy of the easy read summary of the new Mental Capacity Act and has spent time with them talking about their rights to make their own decisions. People are supported by other healthcare professionals such as Community Mental Health Nurses, Consultant Psychiatrists, Psychologists and Occupational Therapists to support people with their health care needs and to develop more appropriate coping strategies with situations that cause anxiety. 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 16 Staff had received training in safe medication practices and medication was stored safely. A measured dose system was used by the home, this is a system where the local pharmacist prepared each person’s medication into blister packs; this reduced the risk of medication errors occurring. Although one person is able to manage their own medicine they prefer to have this stored in the home’s medicine cabinet although they do sign to say they have received the medicine. Two members of staff give out all medicines and both check and sign the medicine given. The balance of medicines held in the home was checked each week by a senior member of staff to identify any discrepancies and was used to contribute to the overall assessment of the quality of the services being provided. The Registered Manager confirmed that should one of the people living in the home developed a terminal illness, all efforts would be made to ensure the person could remain in their home. 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are protected from abuse, neglect and self-harm. People are listened to and complaints or concerns are taken seriously and acted upon immediately. EVIDENCE: The Commission for Social Care Inspection had not received any complaints regarding the service since the last inspection. The home had received one complaint from one of the people living in the home and this had been handled sensitively and appropriately. Each person had been given a copy of the easy read complaints procedure and had these available in their rooms. People are invited to attend the weekly residents meetings to discuss the day-to-day running of the home and any issues of concern. The Organisation’s Responsible Individual visited the home each month to ensure the home is being well-managed and people well supported: the visits were unannounced and reports were available. Staff had been provided with training in the protection of vulnerable adults in their induction programme and additionally with Cornwall County Council: staff were aware of their responsibilities should they suspect a someone is at risk. 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 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. People live in a spacious, safe and well-maintained home, which encourages their independence. EVIDENCE: Pendean Court is a purpose-built home for people who have a hearing loss but who may also have a physical disability. It was found to be clean, tidy and well maintained. The seven bedrooms are all on the ground floor and provide an en suite toilet and sink. The Registered Manager confirmed that there were plans to install showers in each room starting with the vacant room. There are two spacious bathrooms both fitted with equipment to assist people to bathe more independently. 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 19 The communal areas were pleasantly furnished and decorated: the dining room and lounge areas were being repainted in a colour chosen by the people living in the home. The bedroom that had been made into an art and craft room was well used and people enjoy the opportunity to engage in activities away from the main communal areas. The conservatory was a particularly attractive area for people to sit and the entrance hallway has been made more pleasant since previous inspection by the removal of the office equipment and documents. The laundry room was large enough to have 3 washing machine and 2 driers, which enabled people to do their laundry without too much of a delay. There were two offices for use by staff and the Registered Manager, one on the ground floor and one on the first floor. A bedroom and shower room were also provided on the first floor for the use staff who slept in at night. These offices did not encroach upon the communal space within the home. 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Recruitment procedures are robust. Staff are enthusiastic, have a good understanding of the peoples’ needs and work positively to improve their quality of life. EVIDENCE: A sample of staff files were examined, including one for a newly appointed staff member and showed a robust recruitment procedure. All the required information was available, including Criminal Record Bureau checks and 2 written references, ensuring as far as possible only suitable staff are employed. Those people living in the home were encouraged to meet prospective candidates and to join in the interview process. Their views as well as an assessment of how the prospective candidate interacts with those living in the home formed the basis of the decision regarding the candidate’s suitability: this demonstrates very good practice and empowers people to make choices about who they wish to be supported by. 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 21 Regular staff meetings and individual supervision sessions took place and addressed the principles and values of the Organisation, staff performance and training and development needs, as well as day-to-day support issues. All staff were trained in British Sign Language and were expected to use this at all times including in conversations between themselves. The Registered Manager and staff members confirmed that staff were expected to attend relevant training on topics such as supporting people whose behaviour is challenging, including the management of actual or potential aggression, adult protection, manual handling, safe medication practices, fire safety and emergency first aid, ensuring they have the skills and confidence to support people on a day-to-day basis and also at times of crisis. All staff have either gained or are in training for a National Qualification in Care, a qualification which is awarded by an external training body and requires staff to demonstrate their skills and knowledge in supporting people with complex needs. Newly employed staff were provided with a comprehensive 12week induction training programme to introduce them to their role and responsibilities and the people they will be supporting. At the time of the inspection there were 2 staff on duty in addition to the Registered Manager. Discussions with the staff and the examination of the duty rotas confirmed that staffing levels varied throughout the week to allow people to participate in individual activities in and out of the home, for example five staff were available on at least three days of the week. There is an ‘on call’ system whereby members of the management team are available out of office hours each day to offer guidance, support and additional staffing if necessary. Those staff spoken to had a very positive attitude towards the support they gave people to develop new skills, to live as independently as possible and to enjoy a lifestyle that was meaningful and rewarding. Staff were observed throughout the inspection to interact with the people living in the home and each other in an informal, friendly and respectful manner. 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 and 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management approach is open, inclusive and positive, providing clear leadership and guidance. Peoples’ rights, health, safety and welfare are protected and promoted. EVIDENCE: The Registered Manager is well qualified, holding a National Vocational Qualification at level 4 in Care and the Registered Manager’s Award. These qualifications required Ms Nicholls to demonstrate her knowledge and skills in managing a care home and supporting people with complex support needs. She has been the manager at Pendean Court since early 2006 and has many years’ experience in working in the care profession. 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 23 The quality assurance system consists of a variety of consultation processes to gain the views of those living in the home, their family and other health care professionals regarding the quality of the services provided at the home. There was evidence that six-monthly questionnaires had been provided for those living in the home and sent to their families: the results of the latest survey showed a high level of satisfaction. Weekly residents meetings also provide evidence that issues relating to the management of the home and the support provided is discussed and reviewed. The Organisation’s Responsible Individual had visited the home each month. These visits were used to ensure the home was being managed within the Organisation’s policies and procedures and included reviewing areas such as each person’s support plan, the homes’ financial records as well as those monies being held for safe keeping, issues relating to the management of the home and staff training and supervision. A report of these visits had been sent regularly to the Commission. Fire prevention records evidenced that tests are regularly undertaken on appliances and fire drills had taken place recently to ensure equipment is maintained in safe working order and staff are aware of their responsibilities. People had been provided with an easy read, pictorial fire safety procedure and they were included in the training and fire drills to prepare them should a fire break out. Risk assessments have been undertaken on safe working topics and a Health and Safety Audit had been carried out in May 2007 by the Organisation’s Health and Safety Representative, who is independent from the home, and covered all areas with regard to managing a safe environment in which to live and work. All the records that the home is required to keep regarding incidents and accidents were well maintained and available for inspection. 16 Pendean Court DS0000009208.V352872.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 Adults 18-65 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 4 2 4 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 4 33 3 34 4 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 4 13 4 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 3 3 16 Pendean Court DS0000009208.V352872.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 16 Pendean Court DS0000009208.V352872.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 16 Pendean Court DS0000009208.V352872.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!