Inspection on 23/05/07 for 1 Greville Road

This inspection was carried out on 23rd May 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

1 Greville Road 18/12/08

1 Greville Road 17/01/06

1 Greville Road 05/05/05

1 Greville Road 16/12/04

1 Greville Road 24/06/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 1 Greville Road Shirley Southampton Hampshire SO15 5AW Lead Inspector Liz Normanton Unannounced Inspection 23rd March 2007 10:30 1 Greville Road DS0000012088.V332359.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 1 Greville Road DS0000012088.V332359.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. 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1 Greville Road Address Shirley Southampton Hampshire SO15 5AW 023 8039 3403 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) HM4011Smart@mencap.org.uk www.mencap.org.uk Royal Mencap Society Miss Helen Smart Care Home 7 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (7) of places 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users must be at least 55 years of age. Date of last inspection 17th January 2006 Brief Description of the Service: 1 Greville Road is a residential home providing care and support to 7 older service users with learning disabilities. The home has a condition on its registration that it is unable to admit service users under the age of 55. However the homes standards are measured using the Care Homes for Adults (18-65) because of the complex needs of the service users living within the home. The home is a large domestic style house providing a homely and comfortable appearance inside and out, blending well with other homes in the local area. Each service user has a room of their own that has been decorated and adapted to meet their individual needs and characters. The home is situated in Shirley, a residential area of Southampton. It is close to Southampton City Centre, Shirley High Street and a local amenities store with in easy walking distance. The home is local to Southampton Common and Southampton Sports centre where yearly attractions and community events are held. The home is owned by Hyde Housing and is leased to Mencap, a national organisation providing care and support to service users with learning Disabilities. Weekly Fees start at £400.00 and could be more dependent on need. 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken on 23/03/07 and focussed on what the Commission considers to be core standards for a care home for younger adults as defined in the Department of Health (DOH) National Minimum Standards. We also looked for evidence that the home had complied with previous requirements made. Information was gathered from a variety of sources, which included data being sent to the Commission prior to the site visit, discussion with two service users, completed questionnaires from five service users, feedback from one relative, one advocate and discussion with three staff. We also viewed three service users’ files, staff files were not accessible due to the manager being absent. This information was then triangulated to access outcomes for people living at the home. The overall outcome was that the residents and relatives are very satisfied with the service provided at the home. The home had complied with the requirements made at the last inspection. What the service does well: The manager undertakes to ensure that the home can meet an individual’s needs before offering them accommodation. The home ensures that service users have access to good quality physical health care and provides support for this to be achieved. Service users are able to access the local and wider community, have regular contact with relatives and are involved in a range of activities to make the most of their lives. The homes approach to meeting and advocating on behalf of the residents physical wellbeing is very good. The service provides a clean, welcoming, homely and appropriately equipped and furnished environment to meet the specialist and individual needs of the residents. The home also does well to provide a relaxed and organised environment. The home is committed to staff training and development. Policies and procedures are in place to ensure the safety and welfare of service users and staff. 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 1 Greville Road DS0000012088.V332359.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 1 Greville Road DS0000012088.V332359.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Prospective service users are only admitted on the basis of the home undertaking a full needs assessment to ascertain whether they can meet a persons needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided in the pre-inspection questionnaire told us that the home has not had any new admissions since 2005. This standard was met at the last inspection and the inspector is satisfied that the home undertakes robust needs assessments prior to admission. 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 9 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): Quality in this outcome area is good. Service users are involved in decisions about their lives, and play an active role in planning the care and support they receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at two service users support plans and found these to be person centred and contained all the information required to enable staff to support service users how they wish to be supported. The service users keep a copy of their support plans in their rooms and have access to them at anytime. There was evidence that the support plans are reviewed and that service users are involved in this process. All seven service users have access to an independent advocacy worker who has been assisting them with making decisions about moving from 1, Greville Road due to it’s future closure. 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 10 We had feedback from five completed service users survey forms that informed the inspector that they are able to make decisions about how they wish to live their life. People were observed making choices during the inspection visit. There was positive interaction between the staff and service users. Information provided in the pre-inspection questionnaire informed the inspector that two service users handle their own financial affairs. There was evidence of comprehensive risk assessments on each of the two files viewed and the home takes action to eliminate or minimise the risk to service users. Two service users went out in to the community independently which demonstrates that they are able to manage the day to risks of being out and about in the community. 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is good. People who use the service are able to make choices about their lifestyle, and are supported to maintain/develop their life skills. Social, cultural and recreational activities meet the individual’s expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This service has been inspected under Care Homes for Adults 18-65 due to the diverse needs of the service users and therefore standard 12, which, looks, at education and employment does not apply to this service. There was evidence however that the service users do attend day centres on a part time basis throughout the week which has been a long standing arrangement. In discussion with one service user they told the inspector that they go out in to the community independently for walks and to go shopping and uses public transport or taxi’s to get about. They also said, “ I go to Causeway Bible class 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 12 weekly and attend Live Wire once a fortnight. This person was observed going out independently to the shops in the afternoon. We observed that one service user, was taken out in the afternoon for a drive lunch out, by a support person from a Community Access Agency. In discussion with a member of staff they reported that this was a weekly arrangement. In returned questionnaires from 5 service users one told us that they attend football matches on occasion. At the time of the inspection site visit only 3 service users were at home the others were out at their respective day centre services. In discussion with a member of staff they reported that all the service users are registered to vote on the electoral register. In discussion with one service user they said, “I have a friend who comes to visit me once a week” and they also reported that they visit their cousin once a year. There was evidence in the visitors, handbook that people are visited regularly and are supported to maintain relationships with family and friends. It is the homes responsibility to meet the diverse needs of service users and this includes sexual identity and orientation. In discussion with a member of staff they reported that they understood that know one living at the home was in an intimate relationship and that it was understood that all the service users were heterosexual. They felt that the staff team would be able to offer service users advise/support in this area if they required it. Service users had a daily routine as part of their individual care plan. Those service users with capacity are supported to be as independent as possible to undertake household tasks. In discussion with one service user they said, I tidy my room and clear the table after meals and I do my own washing. One service user was observed setting the table for lunch. Each service users has a key to their bedroom doors to enable them to have privacy. In discussion with a member of staff they reported that some service users are able to open their own mail and that offers needs support from the staff team. Staff on duty, were observed calling service users by their preferred names and the interaction between service users and staff was seen to be friendly and positive. A copy of the weekly menu was on display in the kitchen. This was a set menu and in discussion with staff they reported that the menu is planned based on 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 13 the service users likes and dislikes. The menu appeared to offer the service users a wide and varied choice of nutritional meals throughout the week. The home uses fresh vegetables in food preparation and there was a fruit bowl in the kitchen from which service users can help themselves to fresh fruit. In discussion with staff they reported that service users could help to prepare meals if they wish to. In discussion with one service user they said, “the staff cook the food and it’s lovely”. It was observed that the lunchtime meal was taken in the dining room and service users were able to take their time eating and the mealtime was relaxed and unrushed. 1 Greville Road DS0000012088.V332359.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Details of personal support care needs were detailed in the two service user files seen. We received 5 returned questionnaires and service users informed the inspector that they feel well supported by the staff. In discussion with staff they reported that personal support care is provided in the privacy of service users rooms. The home has a mixed gender staff team so are able to provide intimate care by same gender if requested by the service users. The home has provided one service user with all the technical aids they require to maximize their independence, and support them in transfers, which includes wheelchair, hospital bed, pressure mattress and hoist. 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 15 We looked at two service users files and found them to contain details of individuals health needs. All service users are registered with a local practice. There was evidence that service users have access to the National Health Service as required for yearly check ups and follow up treatment. Records of visits from medical professionals were held in service users files. There was also evidence on the files seen that service users have access to eye tests, hearing tests and dental treatment and chiropody as part as their own going health care support. At the last inspection visit it was recorded that staff, had received training in respect of residents changing health needs and they have been trained in understanding epilepsy, diabetes and how to support people with visual impairments. The staff team have also been trained to take blood sugar level tests for one service user who has diabetes. The home continues to use a Dossett monitoring system supplied by a wellknown high street pharmacy. All medications viewed were safely and correctly stored and accounted for. The home currently supports all service users with the administration of their medication. A requirement was made at the last inspection that staff must be given guidance on when and how to administer “As Required Medications” (PRN). The inspector noted that the home had now provided guidance for staff and complied with the requirement. Information provided in the pre-inspection questionnaire informed the inspector that six staff had responsibility for the administration of medication. There was evidence in the home that these six staff had trained in the administration of medication. A newly appointed member of staff informed the inspector that he had received training in house by an external trainer. 1 Greville Road DS0000012088.V332359.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, and are protected from abuse, and have their legal rights protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In returned questionnaires from five service users 3 informed the inspector that they knew how to complain. One told us they never complain. The home has produced a complaints procedure in large print and in a picture format to enable service users to understand how to make a complaint. Each service user has a copy of the complaints procedure in their room. We received one completed questionnaire from a service users friend who stated that they knew the homes complaints procedure and said, the friend I visit could not be better cared for or happier then at Greville Road.” In discussion with one member of staff they demonstrated that they knew what action to take in the event of a service user making a complaint. In the information supplied in the pre-inspection questionnaire the manager reported that there have been no complaints since the last inspection. In individual discussion with 3 staff they reported that they had attended Safeguarding Adults training. The home had a copy of the Hampshire County Council protecting People from Abuse policies and procedures, which the home adheres to. There have been no abuse allegations since the last inspection. 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 17 The home also has a copy of the Departments of health (DOH) “No Secrets” to support staff in protecting the service users. 1 Greville Road DS0000012088.V332359.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): Quality in this outcome area is good. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On entering the home it was noted by the inspector that the ceiling in the hallway was stained showing evidence of a leak. This was discussed with a member of staff who said the matter had been reported and works had been done to repair the leak and they were waiting for the ceiling to be redecorated. We did a full tour of the home and found that the communal living areas were well decorated and furnished to a good standard providing homely comfortable surroundings for the service users. 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 19 At the last inspection a requirement was made that exposed radiators in bathrooms were covered and that in the period before this a risk assessment must be undertaken of the risk of burning from exposed radiators. It was noted by the inspector that these requirements had been met. It was also a requirement that the bathrooms and shower rooms be decorated and appropriately finished off. The inspector noted that the bathrooms and shower rooms had had works undertaken and were now suitable for purpose. In six of the seven bedrooms the inspector noted that one bedroom had a broken towel holder, which could be a possible risk to a persons health & safety. We also found that the carpet was quite grubby by the side of the bed and the headboard was split and both looked unsightly. The pillows on the bed were flat offering no support to the head and need replacing. The mattress was also overhanging the base of the bed. In a second bedroom it was noted that a cupboard door was broken off the sink unit, this was discussed with staff and they repaired it immediately. There was also a mattress propped up against the radiator, which made the room look unsightly and was also preventing heat from the radiator getting around the room. The staff on duty were notified of this and took immediate action to rectify the matter. One bedroom was noted to have splodges of toothpaste on the carpet near the sink unit. This was discussed with staff who reported that the staff team have been discussing alternative flooring for this room as this was an ongoing problem. It was noted that the pillows were flat in several of the service users bedrooms and the home would be advised to undertake a pillow and bed linen audit and replace those items no longer fit for purpose. In discussion with one member of staff they reported that the home had plans to redecorate one of the downstairs bedrooms. Overall the home was found to be safe, comfortable, cheerful, airy and free from offensive odours and in feedback provided from five service users they have informed the inspector that they consider the home to be clean at all times. The laundry is sited next to the kitchen so therefore articles of clothing and linen are being carried through an area where food is being prepared. This is due to the design of the home and cannot be rectified. In discussion with staff they reported that items for washing are brought through in concealed laundry baskets, which have fitted lids to prevent the risk of food being contaminated. 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 20 Each service users washing is washed separately and the washing machine is fitted with a sluice programme and washes to temperatures, which disinfects harmful bacteria. The floor covering of the laundry room is impermeable. In discussion with a member of staff they reported that service users are provided with aprons to protect their clothing when undertaking their washing and gloves and masks are also provided. 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. Staff working in the home are trained, skilled an in sufficient numbers to support the people who use the service, in line with their terms and conditions and to support the smooth running of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector was not able to access staff files to see evidence of robust recruitment practices this was due to the fact that this was an unannounced inspection and the manager was not present. We have previous knowledge that Mencap have robust recruitment procedures and the inspector was satisfied that these procedures where still being implemented after having been in discussion with one most recently employed staff member and a member of bank staff. Both members of staff reported that they had completed questionnaires, provided identification, 2x references and attended a formal interview had completed Criminal Record Disclosure (CRB) checks and had not been employed until Mencap had receipt of these checked documents. At the last inspection the inspector viewed the records of the newest appointed member of staff and found all necessary checks such as CRB (Criminal Record Bureau), POVA (Protection of Vulnerable Adults) and references to be in place. 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 22 In discussion with three members of staff they reported that they had undertaken training specific to their roles and responsibilities. A recently appointed member of staff reported that they were undergoing induction training and had completed mandatory training in health & safety, moving & handling, fire safety, food hygiene, and infection control and medication administration. They had also undertaken epilepsy training, person centred support planning, rectal diazepam administration and safeguarding adults training. In discussion with the bank staff they reported that they have been provided with training from Mencap during their employment. They reported that they had been trained by staff that were deemed competent by the district nurse to take bloods using an EPI Pen. The information provided in the pre-inspection questionnaire evidenced that three staff have completed National Vocational Qualification (NVQ) training this figure falls below the government expected figure of 50 which should have been attained. However the manager has indicated on the pre-inspection questionnaire that three additional staff will start NVQ training this year. 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good. The management and administration of the home is based on openness and respect and has effective quality assurance systems which has been developed by a qualified, competent manager. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager was not present in the home during the site visit and was therefore unavailable for discussion with regards to future plans of the home. Information provided in the pre-inspection questionnaire indicates that the manager has reviewed and updated the homes policies and procedures since the last inspection. 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 24 The home, have developed a positive enabling monthly questionnaire which they use with the service users, to establish their views about the running of the home. In discussion with a member of staff they reported that an area service manager from Mencap visits the home annually and regular monthly audits are undertaken. With regards to safe working practices the manager ensures that all staff have undertaken mandatory training in moving and handling, health & safety, food hygiene, infection control and fire-safety. There was evidence that fire systems are checked weekly and records kept. One service user demonstrated by drawing a picture that they would know what to do if there was a fire. The home safely stores hazardous substances in a locked cupboard when not in use and a COSHH risk assessment had been undertaken. The kitchen was clean and food was safely stored in the fridge. There was evidence that the staff check the fridge and freezer temperatures twice daily. It was noted that fresh vegetables was being kept in the utility room were soiled clothing is laundered the staff were asked to move this to a more suitable site which they did immediately. There was evidence that electrical and gas installations are checked as required. The manager ensures that staff comply with health and safety legislation buy providing training, discussion in supervision and through staff meetings. 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 25 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 x 2 3 3 x 4 x 5 x 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 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 3 35 3 36 x 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 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? 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 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 1 Greville Road DS0000012088.V332359.R01.S.doc Version 5.2 Page 28 - 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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