Inspection on 23/08/06 for 1 Sheepfold Avenue

This inspection was carried out on 23rd 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 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 Sheepfold Avenue 27/06/08

1 Sheepfold Avenue 13/12/05

1 Sheepfold Avenue 16/07/05

1 Sheepfold Avenue 07/02/05

1 Sheepfold Avenue 24/08/04

1 Sheepfold Avenue 28/01/03

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

CARE HOME ADULTS 18-65 1 Sheepfold Avenue Rustington Littlehampton West Sussex BN16 3SQ Lead Inspector Mrs J Aston Unannounced Inspection 23 August 2006 10:50a rd 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 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 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 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 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 1 Sheepfold Avenue Address Rustington Littlehampton West Sussex BN16 3SQ 01903 785753 01903 859962 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.mencap.org.uk Royal Mencap Society Ms Josi Mellor Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only persons aged between 18 and 65 years may be accommodated Date of last inspection 13th December 2005 Brief Description of the Service: 1 Sheepfold Ave is a care home registered to provide personal care support (PC) and accommodate up to six service users with a learning disability (LD) between the ages of eighteen and sixty-five. It is a detached property located within a short distance from Angmering and Rustington. The property provides accommodation consisting of all single rooms, lounge, dining room, sensory room and easy access to the garden at the rear of the property. The service provides personal care assistance to service users who have a profound learning disability and physical disability. Support and assistance is also provided to enable service users to access facilities and activities at home and in the community to ensure they lead an active lifestyle. The Royal Mencap Society owns the service. The Responsible Individual operating on behalf of the organisation is Ms Janine Tregelles. The Registered Manager responsible for the day-to-day running of the home is Ms Josi Mellor. Charges for the service range from £915.19 to £1487.01. 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at 1 Sheepfold Avenue will be referred to as ‘residents’. This inspection is the first inspection in 2006-2007. It is called a key inspection and will determine the frequency of inspections hereafter. Only the key standards determined by the Commission have been assessed during this inspection. Planning for this inspection took place prior to the site visit. A pre-inspection questionnaire was received prior to the site visit and some of the information provided will be referred to in this report. Surveys were sent to relatives by the home and the Inspector sent comment cards to Professionals who know the service. A site visit took place on the 23rd August 2006 and was an unannounced visit. Five hours were spent in the home. A tour of the premises was undertaken, three members of staff were spoken with and a sample of records was examined. Three service users were seen during the visit however the Inspector was not able to converse with each service user due to their level of disability and communication difficulties. The Deputy Manager facilitated the site visit. Feedback about the service has been obtained through comment cards from one relative, a Care Manager, a G.P. and Doctor in Psychiatry. What the service does well: A relative and Professionals who responded to the inspection through comment cards indicated that they were all satisfied with the overall care provided at Sheepfold Ave. A Care Manager said, “1 Sheepfold Ave offer an excellent service to the residents there”. Residents’ individual care plans provide comprehensive and detailed information about each resident that ensures that members of staff are aware of their needs and the support they require. Activities for residents’ are well managed and a recent project undertaken by the Registered Manager and members of staff has reviewed current activities and explored new activities and new ways of providing these. This demonstrates that the home is working to ensure that residents have new opportunities made available to them and a variation in routine. 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 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. 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 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 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 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): 2. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The needs of prospective residents are appropriately assessed. EVIDENCE: There is one vacancy in the home. There have been no new residents admitted to the home since the last inspection. The Deputy Manager explained to the Inspector that there has only been one prospective resident referred for the vacancy however the home was found to be unsuitable for their needs. The organisation has a comprehensive admission policy and procedure in place for Registered Managers to follow to ensure that the needs of the resident can be met. 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 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 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 from evidence gathered both during and before the visit to this service. The needs and wishes of each resident are recorded appropriately so members of staff have clear guidelines and information available to them when working with each service user. Formal assessments and reviews of residents’ needs and placement within the home should be undertaken on an annual basis to ensure that the needs of each resident continue to be met. Members of staff support residents in a way that enables them to make choices and decisions in their lives. Each resident is supported to take considered and appropriate risks in order for them to increase or maintain their independence. EVIDENCE: The Individual Care Plans for each resident were examined at the site visit. It was noted that the work to improve care plans is now complete. All residents’ plans now use an updated format that provides comprehensive information about the needs and wishes of each resident. There was evidence that the care plans had been reviewed. 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 Page 10 A key worker system is in operation in the home that allocates a member of staff for each resident. The key worker is responsible for giving written information about the resident to their manager on a monthly basis to ensure that the care plan is up to date. Formal reviews for residents that seek involvement from relatives and a Social Worker are outstanding for three of the residents. An assessment of each resident’s needs undertaken by a Social Worker have not been undertaken for some time. Formal reviews should be undertaken on an annual basis to ensure that relatives and Professionals are involved and have an input into the care provided. Social work assessments should be undertaken at least annually to ensure that the resident’s needs are still being met by the home and that the funding of the placement is still at the correct level. It was observed during the inspection that members of staff offered choices to residents. However due to the level of disability of some residents decisions have to be made in their best interests. It is recommended that the Registered Manager ensure that the service provided takes into account the requirements and recommendations made by the Mental Capacity Act 2005 to ensure that members of staff are working in line with current legislation. There was evidence that potential risks for residents had been assessed and recorded on a risk assessment. Risk assessments were noted to be individual for each resident and covered bathing, road safety, travelling in vehicles etc. It was noted that the risk assessments had been reviewed. Where a review had taken place and changes made it was noted that each member of staff signed to confirm they had read and understood the reviewed document. This demonstrates that risks for residents have been considered and minimised as far as possible and members of staff are aware of how to work to minimise those risks. 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Activities for residents are creative and well managed. The Registered Manager and members of staff maintain good relationships with relatives and involve relatives in decision making wherever appropriate. The routines within the home take account of residents’ activities and choices. Residents are supported to eat a healthy and balanced diet that also takes their choices into account. EVIDENCE: From examining information in residents’ files it was evident that residents are supported to undertake a wide range of activities. This supports them with maintaining independence, provides stimulation and physical and educational activities. Activities range from attending day centres where they are involved in art, cooking, sensory sessions to activities at home that includes reflexology, swimming. Residents also have equipment in their rooms for individual activities and there is a sensory room available to them in the home. 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 Page 12 During a tour of the premises it was noted that where a resident had communication difficulties a record had been kept in his room of when he had last watched a DVD or video to prevent the same video being played over and over again. There was evidence that the Registered Manager and staff team are regularly considering the range of activities that residents are involved in and how they are provided. An alternative activity programme for residents was piloted in the home for two weeks in July. This provided a range of activities within and from the home rather than residents attending day centres. The Deputy Manager informed the Inspector that this had worked well and had fully involved residents. A project like this ensures that residents have new opportunities and experiences available to them and new routines are explored. There was evidence that the home assist residents to maintain relationships with relatives. A Parent visits the home regularly and the resident has regular overnight stays in the parents’ home. Where a review had taken place the relatives of the resident had been invited and attended the review. A relative confirmed through a comment card received prior to the inspection that they were made welcome in the home at any time, can visit their relative in private, are kept informed about important matters affecting their relative, and are consulted about their care. Daily routines in the home are based around activities but can be flexible dependent upon a resident’s wishes or behaviour. It was noted during the visit to the home that residents are free to choose where they wish to spend their time when in the home. A member of staff spoken with said that the times for residents getting up and going to bed were all different and dependent upon their wishes and their activities. Members of staff compile a menu of a range of meals that have taken residents’ likes and dislikes into account. All meals are cooked and prepared by members of staff. Members of staff base the food shopping for the home on the planned menu. When shopping for food residents will go with the member of staff whenever possible. Members of staff spoken with confirmed that the menu is flexilbe but they have to keep a note of the change of meal. It was noted that the weight of each resident is monitored and recorded along with a note of what they have eaten each day. On the day of the visit to the home sandwiches were prepared for lunch which was a change to the menu and the main meal was provided in the evening. One resident likes fish & chips and the Inspector noted from discussions between staff that this would be bought with him after his swimming session in the evening. 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 Page 13 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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents’ personal care and health needs are met appropriately. The service operates effective and safe procedures in the administration of medication. EVIDENCE: Residents care plans give very comprehensive information about how to assist each person with personal care. Where residents are unable to communicate this to staff and where moving and handling equipment is used the guidelines are very specific. Members of staff work through the induction and foundation programmes provided by the organisation and are assessed in the home when working with each resident before being allowed to work alone with resident. This ensures that they are confident in communicating with each resident and have received and understand instructions about how to move them. It was noted that a Health Assessment had been undertaken for one resident and the Inspector was made aware that they are to be completed for all residents. This provides a good record about all aspects of a resident’s health that includes past history. 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 Page 14 Where necessary a record is kept of continence, seizures, weight and behaviour. There was substantial evidence of contact with Doctors and Consultants in respect of Health matters and a record kept of any advice or changes in treatment or medication. There was evidence that all residents had received an eye test recently. One Doctor and one Senior House Officer in Psychiatry completed comment cards prior to the inspection. They confirmed on the comment card that the home communicates clearly and work in partnership with them, there is always a senior member of staff to confer with, they are able to see the resident in private, any specialist advice given is incorporated into the care plan and that staff demonstrate a clear understanding of the care needs of residents. From all the records examined and information received there was clear evidence that the Registered Manager and staff team monitor and take prompt and appropriate action in respect of any health matter. During the visit to the home the storage and handling of medication was explored. A Deputy Manager has overall responsibility for the safe handling of medication. The Inspector found that all medication was stored appropriately. An observation of a member of staff giving medication to a resident demonstrated that this was done appropriately. The records relating to the medication administered were in good order. Each resident has a pen picture in relation to what medication he or she is taking and what it is for. This enables staff to understand what each type of medication is for and to be aware of any side affects from the medication. Where a resident has medication as required there is clear criteria in place to enable members of staff to decide when this medication should be given and always two members of staff make the decision. Where a resident may need to take medication with food or in drinks their G.P. had been consulted and had given their consent. The comment cards from the Health Professionals confirmed that the residents’ medication is appropriately managed. Training records confirm that all staff had received training in safe handling of medication in either 2004 or 2005. The procedures that were seen to be in place follow the guidance from the Royal Pharmaceutical Society and ensure that the service operates effective and safe procedures. 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 Page 15 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 from evidence gathered both during and before the visit to this service. There is a comprehensive complaints procedure to ensure that complaints are dealt with appropriately. The service has ensured as far as possible that residents are safeguarded from abuse. Residents’ finances are managed appropriately. EVIDENCE: The Commission has not received any complaints in respect of this service. The Registered Manager informed the Inspector that there have been no complaints made to the home. A relative who responded to the inspection through a comment card confirmed that they are aware of the homes complaints procedure but have never had to make a complaint. The three Professionals who completed comment cards prior to the inspection also confirmed that they had not received any complaints about the home. An allegation of abuse has been received since the last inspection and an investigation is still ongoing and therefore remains an allegation. The Manager has reported the allegation appropriately and taken the correct action. There appears to be no breaches in regulation in connection with the allegation. Training records examined confirmed that ten members of staff had received training in recognising signs of abuse and adult protection procedures this year. Where members of staff work with challenging behaviour there are now some very clear guidelines to follow if any form of physical intervention is required. The use of photographs gives members of staff some very clear instructions about minimal intervention techniques. 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 Page 16 All residents are supported to manage their finances. One resident’s relatives take overall responsibility through Power of Attorney. Residents’ Social Security benefits are paid directly into an individual Building Society Account. The Manager and members of staff are signatories for withdrawal of money from this account. The service assists residents to pay their rent and financial contribution to the service from this account and buy personal items. All transactions are recorded and receipts kept. The records are monitored and audited by the Manager and as part of the Regulation 26 inspections and through a more formal audit by the organisation. 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 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, 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The standard of accommodation provided for residents is good and provides a safe environment. EVIDENCE: A tour of the premises was undertaken and records in relation to the safety of the property examined. The ground floor of the home consists of lounge/dining room, kitchen, two residents bedrooms, bathroom, toilet, storeroom, laundry and a sensory room. The first floor consists of a lounge, four residents bedrooms, bathroom, toilet and office/sleeping in room for staff. There is a small garden at the rear of the property that is accessible for residents. Residents’ rooms looked individually decorated and furnished and suitable for their needs. The home looked clean throughout and well maintained. 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 Page 18 Records examined and information provided on the pre-inspection questionnaire demonstrated that safety checks on the property and utilities are regularly undertaken and comply with safety legislation. 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 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): 32, 34, 35, 36. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are supported by a trained staff team who have sufficient time to meet their needs. There are good recruitment procedures and individual supervision of staff is regularly undertaken. EVIDENCE: A sample of training records demonstrated that all staff had undertaken a wide range of training from induction through to National Vocational Qualifications (NVQ) level 2 & 3. 50 of the staff team have now been trained to NVQ level 2. Training in Health & Safety topics had been undertaken at induction and updated as required. Specific training in topics relevant to the needs of the residents had also been undertaken. Members of staff confirmed that this training had been provided and that updates in Health & Safety topics are being updated again this year. 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 Page 20 The staffing levels during the visit to the home appeared appropriate for the needs of the four residents. A member of staff spoken with confirmed that the staffing levels in the home are usually sufficient to meet the needs of the residents within the home and to take them out to their individual activities. There has been one new member of staff since the last inspection. The records relating to the recruitment of this member of staff were examined. This demonstrated that the necessary recruitment checks had been undertaken prior to the member of staff starting to work in the home. A member of staff spoken with confirmed that they receive regular supervision and staff meetings are usually held regularly. Records demonstrated that ten members of staff have received two supervision sessions so far this year and four only one session. It is recommended that the Registered Manager arrange supervision sessions as a matter of priority to those members of staff that have received only one session. 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 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, 39, 42. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is well maintained and safe for service users. The safety of service users and members of staff is considered and risks minimised as far as possible. EVIDENCE: The Registered Manager is qualified, competent and experienced to run the home. Ms Mellor has achieved a National Vocational Qualification level 4 and has completed the Registered Managers Award. The Registered Manager undertook a quality assurance exercise for the year 2005 that resulted in a comprehensive development plan for the home. There was evidence provided with the pre-inspection material that a quality assurance exercise for the home for this year is currently being undertaken. This has involved requesting feedback about the service from relatives. 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 Page 22 The organisation undertakes a formal quality assurance exercise and the Inspector is aware that this was undertaken in 2005 and had a good outcome. Training records and other documentation relating to the safety of the home provides evidence that the Registered Manager ensures the health, safety and welfare of residents and staff. Records relating to the premises and equipment were seen on the day of the inspection. These demonstrated that annual safety inspections are undertaken on equipment and utility supplies and maintenance systems are in place to ensure the safety of residents. An Environmental Health Officer had visited the home in August and had commented on good practice in the areas of training policy, appreciation of controls and stock taking and good record keeping. The records examined that related to a new member of staff provided evidence that an induction and foundation course had been completed. Training records demonstrated that all staff had undertaken an update in moving and handling training this year and other Health & Safety training was provided and updated as necessary. It was noted however from these records that there were two members of staff who had not undertaken all of the mandatory Health & Safety training. It is recommended that the Registered Manager make this a priority for these staff. The accident record was examined and demonstrated that members of staff are good at recording any accident or incident however minor. The Registered Manager is required to provide numbers of accident and incidents to the organisations head office. This demonstrates that a good record is kept and that an analysis is made for any pattern or reason for accident or incidents. 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 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 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 3 33 X 34 3 35 X 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 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 Page 24 No 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 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Southampton Hub 4th Floor, Overline House Blechynden Terrace Southampton Hampshire SO15 1GW 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 1 Sheepfold Avenue DS0000014264.V290622.R01.S.doc Version 5.1 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. 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!