Inspection on 31/08/06 for 1 Betjeman Court

This inspection was carried out on 31st August 2006.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 Betjeman Court 12/05/08

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Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Betjeman Court, 1 1 Betjeman Court Offmore Farm Estate Kidderminster Worcestershire DY10 3GN Lead Inspector Dianne Thompson Unannounced Inspection 31st August 2006 10:00 Betjeman Court, 1 DS0000066858.V309715.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 Betjeman Court, 1 DS0000066858.V309715.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. Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Betjeman Court, 1 Address 1 Betjeman Court Offmore Farm Estate Kidderminster Worcestershire DY10 3GN 01562 747268 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) www.dimensions-uk.org Dimensions (UK) Ltd Mrs Susan Mary Brain Care Home 5 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (1), Mental disorder, excluding of places learning disability or dementia (1), Physical disability (1), Sensory impairment (1) Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13.12.2005 Brief Description of the Service: The home is located in a residential area of Kidderminster and, from the outside, looks like two semi-detached houses although the interior is individually designed. The home provides residential care, for up to five adults with learning disabilities. Some of the service users have additional physical disabilities. One service user is over sixty-five years of age but has no additional age related needs. The home aims to provide personal care and support that most effectively meets the needs of service users. This includes promoting independence and opportunities to make real choices in every day life. The home is committed to helping service users to achieve valued and fulfilling lifestyles. Dimensions (UK) Ltd is now the care provider for the service having been contracted by Worcestershire Social Services and registered with CSCI with effect from 1st April 2006. The fees range from £312.00 to £330.00 per week. Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that included an unannounced visit to Betjeman Court. The main purpose of this inspection was to assess the service provided against key National Minimum Standards. Service user and staff records were examined, and case tracking was completed for two service users. A tour of the building was also carried out. Accumulated evidence from reports of monthly visits by the provider’s representative and notifications were used to inform this report. Time was spent with three service users, the registered manager and staff on duty. What the service does well: Betjeman Court is located in a residential area of Kidderminster. The home provides a residential service for five people with learning disabilities. The home is welcoming and comfortable. Information is provided about the services offered at the home to help service users make an informed choice about whether they would like to live at Betjeman Court and whether the home will meet their needs. Service users receive help and encouragement to lead active and interesting lives and are supported to access facilities within the wider community. They are also supported to maintain links with their families and to develop friendships. The home offers a well-balanced menu and promotes healthy eating. Personal and healthcare needs are clearly identified in care plans. These plans provide information to make sure that care is provided in a consistent way and in a way that Service Users prefer. The home has a clear medication policy and procedure, which is followed to make sure that all medication is given and stored safely for the protection of service users and staff. The home’s complaints procedure is available in easy to understand information about how to complain. Staff support service users to express their views and any concerns they may have. Betjeman Court is a suitable home that meets the service user needs. It offers a safe, spacious and comfortable home. The home is kept clean with good hygiene and infection control. Staff receive relevant training to help them meet service users’ needs. The staff team understand their responsibilities and are committed to their role. They are well supported and work together to provide service users with consistent and good quality care. Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 6 The home’s recruitment policy and practices make sure that suitable staff are employed and that all necessary checks are made to ensure the safety of all service users. The home is managed with an open and positive approach. Dimensions monitor the home in various ways to ensure that the service continues to develop as service users want and that the home remains a safe place to live and work in. 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. Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 7 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 Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Detailed information is provided about the services offered at the home to help service users make an informed choice about whether they would like to live at Betjeman Court and whether the home will meet their needs. Licence agreements that specify the terms and conditions for living in the home are out of date and have been issued by the new care provider. EVIDENCE: The home’s statement of purpose and service user guide provides information about the home to help prospective service users to decide if they wish to live at Betjeman Court. All prospective service users would receive copies of the relevant information prior to moving into the home. All information is available in alternate formats, e.g. with symbols/pictures. There are five service users currently living at Betjeman Court. The home’s assessment and admission process is very detailed and the manager says the home will make sure all procedures are followed should a vacancy occur. The care records demonstrate that the home receives full information about prospective service users, their background, their needs, their likes and dislikes when they are referred for a placement. Introductory visits and stays would be arranged at the home prior to admission. During the introduction to the home prospective service users would be given a copy of the statement of Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 9 purpose and service user guide, which the manager confirms has been updated to include pictures of the home and the surroundings. Licence agreements that specify the terms and conditions for living in the home were seen on individual files. These agreements are however out of date and have not yet been issued by the new care provider. Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Person centred care plans provide staff with relevant information about users assessed needs. They include risk assessments detailing how risks are to be reduced and independence promoted. Service users are enabled to make choices and decisions in their daily lives and routines. EVIDENCE: All service users have informative care plans that are up to date, with reviews being conducted regularly. The care plan format is being changed to a person centred format that will indicate individual likes, dreams and goals. The home and the staff team have completed some training towards this and Paths for the home and the service are being completed as part of this development. Files for two service users were examined. Case tracking provides a view of how the home responds to the diversity of needs and how this is being managed and supported. This is particularly evident where health needs and disability requires greater input and support from all staff within the home. Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 11 Relevant information and monitoring is provided to make sure all staff have the necessary information in order to provide quality care. The inspector observed day-to-day operations within the home, particularly staff and service user interaction. Time was spent with three service users, and although communication was limited it is evident that people are comfortable in their home and relaxed with members of staff. Staff were seen to encourage participation in the home’s activities, treating all service users respectfully. Choices were observed being offered. Service users are encouraged to make choices and act upon them, e.g. choosing what they want to drink, to be involved in the making of a drink and assisting with/washing up the cup afterwards. All members of the staff team use objects of reference to support people in the choices they make ensuring a consistent approach. Risk assessments are completed for all service users to identify how risks are to be reduced and independence promoted for all service users. At the time of the inspection some risk assessments had not been reviewed and were out of date. The registered manager has confirmed that following the inspection visit the review of all risk assessments has been completed. The home should develop a system that identifies when risk assessments are due to be reviewed where there may be no (apparent) changes to the level of risk. Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Service users receive help and encouragement to lead active and interesting lives and are supported to access facilities within the wider community. They are also supported to maintain links with their families and to develop friendships. The home offers a well-balanced menu and promotes healthy eating for the welfare of all service users. EVIDENCE: All individual activities are recorded on Activity Record Sheets. Planned and unplanned activities are recorded and colour coded to assist with audits, which are completed three monthly. Household activities include cleaning their bedroom, food shopping, cleaning cars, gardening/watering the plants, basketball, and playing the keyboard. External activities include attending Meadow Mill day centre, pottery classes, animal husbandry at Sunfield in Clent, shopping and cinema. The home has a Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 13 list of suggested activities for service users and staff to refer to, detailing both in house and local community activities for consideration. Service users are supported to take holidays each year, and a trip for two service users to Blackpool with two staff is planned. Another service user is planning to holiday in Burnham on Sea in September. Family visits to and from the home are actively encouraged and supported. Staff said that regular contact is organised and supported for service users. Service users are offered a varied and healthy menu. A record of menus is available, and a record of all food intake and fluids is recorded. Meals include and promote fresh fruit and vegetables. The home caters for a variety of dietary needs including diet-controlled diabetes, reduce/maintain cholesterol levels and low fat diets. Diabetic food charts that provide details of foods to avoid with suggested alternatives are available for service users and staff, e.g. guidelines offer alternatives such as Weetabix, bran flakes or shredded wheat instead of sugar coated cereal such as Alpen. One member of staff told how service users are being offered more choices. Everyone now has their own box in the store cupboards with foods they like to eat, e.g. apples. Service users can help themselves to their boxes whenever they want to. Similarly the same practice is being encouraged with foods kept in the fridge. On the day on the inspection visit omelettes and salad was planned for lunch. A choice of fruit was available for dessert. Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Personal and healthcare needs are clearly identified in care plans. The plans provide information and promote consistency of care and support for all service users in a way that takes into account their preferences. The home has a clear medication policy and procedure, which is followed to make sure that all medication is administered and stored safely for the protection of service users and staff. EVIDENCE: Service users’ care records and plans provide detailed information about their physical and mental health and the support needed from staff to maintain their good hygiene and health. The care plans sampled contained information about service users preferred personal care routines. Through discussion with the registered manager it is evident that the home is responding to the changing needs of service users. Care plans demonstrate that the home is able to closely monitor and respond to changes and obtain appropriate medical input whenever necessary. Evidence of this was seen in Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 15 relation to Psychologist involvement, including referrals that have been made to the Occupational Therapist and Physiotherapist for full mobility assessments. Weight charts are completed for service users, but one chart indicated that weight should be recorded every 3 months. Weight however was not being completed at the specified intervals, with varying gaps between recordings e.g. 5 months, 7 months, and 3 months. The registered manager has confirmed that since the inspection visit this has been addressed. Service users and the home are well supported by medical services, which includes GP’s, dentist, community learning disability team, physiotherapist, occupational health, and dietician. All service users have given consent to their medical treatment and a record of this is kept on their files. Arrangements are in place for preventative health services, e.g. dental checks and annual health screening. Staff on duty and the registered manager say that all personal care is given in private to promote dignity for all service users. The manager is aware of the specialist services that could be needed to support service users and how to access them. There are guidelines in place for the management of pain and management of asthma. Risk assessments are completed for generic and specific care for all service users. As with risk assessments referred to on page 13, some risk assessment reviews were overdue. The registered manager has confirmed that all reviews have been completed and are now up to date. The home has a medication policy and procedure in place. Medicines are suitably and safely stored and there is appropriate storage for controlled drugs, should they be required. Medication storage and records were checked and all was satisfactory. A life book that provides details of family history including photos for each service user is being compiled as part of pre-bereavement education. This includes some role-play, the use of a video and instruction into death and dying. Service users are being supported to help them understand about death and dying in preparation for when they experience bereavement. Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Service users are protected by the home’s complaints procedure that is available in easy to understand information about how to complain. Appropriate information is provided for staff to make sure service users are protected. Staff support service users to express their views and any concerns they may have. EVIDENCE: The home has relevant policies and guidelines in place that advise and guide staff on how to protect service users. This includes the complaints and financial policies and procedures. The home’s complaints procedure is available in widget signs and symbols. There have been no complaints since the last inspection, either to the home or to the Commission for Social Care Inspection. The registered manager confirmed this. The home has an Advocate Complaints Procedure that was described by the registered manager as a ‘voice for the service users’. The homes’ Adult Protection Policy on abuse refers to the vulnerable adults team and the Dept of Health ‘no secrets’ guidance. A member of staff demonstrated an awareness of the home’s adult protection policy and emergency procedures. This included knowledge of the organisations on call system and how to respond in the event a Service User was to be missing. The member of staff said it is ‘about being aware of the risks and minimising them’. Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Betjeman Court provides accommodation for service users that meets their needs and offers a safe, spacious and comfortable home. The home is kept clean which ensures that good hygiene and infection control is maintained for the benefit of service users. EVIDENCE: The home is located in a residential area of Kidderminster and, from the outside, looks like two semi-detached houses although the interior is individually designed. There is a large lounge, a hallway and a separate kitchen/dining room available to service users as communal space. All service users have single bedrooms. The garden to the rear of the property is attractively laid out with easy access for all service users. The home is scheduled for some redecoration and refurbishment. It is disappointing that work has not been completed since the previous inspection. The home is awaiting kitchen refurbishment and conversion of the upstairs bathroom/toilet into a shower and toilet facility. Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 18 The registered manager stated that the home now has a local budget for the small maintenance work around the home. One Service User’s bedroom is due to be redecorated, with the service user choosing the colour scheme. One Service User said she liked her room very much, and was observed to be comfortable in her surroundings and able to move about the home freely. The home also has a cat. Specialist equipment is available to those people who need assistance. An example of this equipment includes a mattress variator that inflates to assist getting out of bed, and a wheelchair for outings. The premises are clean and tidy. Policies & procedures for infection control are in place and staff are provided with disposable gloves and aprons. Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. The staff team understand their responsibilities and are committed to their role. They are well supported and work together to provide service users with consistent and good quality care. Staff receive relevant training to help them meet service users’ needs. The home’s recruitment policy and practices make sure that suitable staff are employed and that all necessary checks are made to ensure the safety of all service users. EVIDENCE: The home is working through a period of transition following the appointment of a new provider – Dimensions. The transition appears to have been fairly smooth, and staff say this has been a positive experience. The home has staff shortages and needs to recruit new staff. The registered manager said that staffing levels should be increased following the successful recruitment of two new staff. Staff said that service users have not been able to get out as much, and that it has been difficult for the staff team, although everyone has worked together well to support the service users. Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 20 Suitable recruitment policies and procedures are in place and the manager confirmed they have been followed for the two new staff waiting to commence employment. All checks have been carried out including Enhanced Criminal Records Bureau (CRB) checks. A sample of staff records was examined. The manager confirmed that all prospective staff complete an application form and that appropriate references are obtained including one from their most recent employer. All staff are required to work a probationary period at the home. Bank staff are employed specifically to work at Betjeman Close. Additionally, the home uses agency staff that are known to the home and service users. The registered manager confirmed that over 50 of the staff team are currently qualified to NVQ standard. Two members of staff are working to complete the NVQ award. The registered manager has completed the Registered Managers Award. All staff within the home will be completing Dimensions Induction training course that includes introduction to the Organisation, its policies and procedures. The staff training record log was seen. Mandatory training courses have been arranged for the forthcoming year through Dimensions training department and includes medication, Our Approach, fire training, Quality Outcomes, Key Skills, and Wheelchair support Training. The staff supervision record log was seen which demonstrates that regular staff supervision is being completed. Staff meetings are also held monthly. A member of the staff team confirmed this. Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42, 43 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. The home is managed with an open and positive approach. The registered manager has completed the Registered Managers Award, which should be beneficial to the service users and the staff team. Dimensions monitor the home in various ways to ensure that the service continues to develop as service users want and that the home remains a safe place to live and work in. EVIDENCE: The registered manager Mrs Susan Brain confirms that she operates an open style of management. Staff confirmed the manager is approachable and will ‘always sort things out’. Service users were seen to get on well with the manager and the staff on duty. Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 22 In respect of management support from the provider, Dimensions has Training and Human Resource Officers who are available to advise and support the home. An Operational Manager regularly visits the home and provides supervision for the manager. Service manager meetings are held monthly. The provider’s monthly visits are one of the ways that Dimensions monitors the service and how the home is being run. These visits include interviews with staff and service users and also include an audit of selected areas of the service, including records, environment, complaints received, finance and safety. Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 23 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 3 2 3 3 3 4 3 5 2 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 2 29 3 30 3 STAFFING Standard No Score 31 3 32 X 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 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 X X 3 3 Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5 (1) (3) Requirement Licence agreements that specify the terms and conditions for living in the home are out of date and must be issued by the new care provider. Timescale for action 20/10/06 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 YA9 Good Practice Recommendations The home should develop a system that identifies when risk assessments need to be reviewed where there are no changes to the level of risk. Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 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 Betjeman Court, 1 DS0000066858.V309715.R01.S.doc Version 5.2 Page 26 - 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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