Inspection on 14/11/06 for 1 Williams Street

This inspection was carried out on 14th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Williams Street 04/11/08

1 Williams Street 31/10/05

1 Williams Street 08/06/05

1 Williams Street 10/11/04

1 Williams Street 28/06/04

1 Williams Street 09/02/04

Similar services:

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 1 Williams Street, Fenton Stoke-on-trent Staffordshire ST4 2JG Lead Inspector Mr Berwyn Babb Key Announced Inspection 14 November 2006 09:30 1 Williams Street, DS0000008217.V319342.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 Williams Street, DS0000008217.V319342.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 Williams Street, DS0000008217.V319342.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1 Williams Street, Address Fenton Stoke-on-trent Staffordshire ST4 2JG 01782 746361 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) Choices Housing Association Limited Mr John Christopher Richardson Care Home 6 Category(ies) of Learning disability (1), Learning disability over registration, with number 65 years of age (6), Physical disability (1), of places Physical disability over 65 years of age (6) 1 Williams Street, DS0000008217.V319342.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 1 - Learning Disability minimum age 43 years 1 - Learning Disability minimum age 26 years Date of last inspection 31st October 2005 Brief Description of the Service: William Street is a purpose built residential bungalow standing in its own grounds, the service is operated by Choices. The home provides 24-hour care for six service users with a learning disability, some of whom are over the age of 65 years, but whose primary feature remains their Learning Disability. Facilities comprise of 6 single bedrooms, which are well decorated and furnished, all have wash hand basins. The lounge/dining area is open plan and spacious, and leads onto a domestic style kitchen, a separate laundry/utility room is also provided. Assisted bathing and shower facilities are provided in addition to two separate adapted toilets. The whole bungalow is accessible to wheelchair users. The rear garden is accessed via a ramp, which has handrails; it has seating areas for the benefit of service users, and appeared well maintained. The front driveway of the property provides off road parking. The home is situated in Fenton, with easy access to the main towns of Hanley and Longton, and is in walking distance to local shops, post office, and public houses, take aways and newsagents. All Primary Health care facilities are within four a four-mile radius of the home. 1 Williams Street, DS0000008217.V319342.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This primary unannounced key inspect was carried out during the afternoon and early evening of Tuesday, November 14, 2006. The care manager was in attendance throughout the inspection, and at all times there were two members of care staff, there been any change of shift shortly after the inspection started, so there were four people on duty for a short period. One of the residents was away from the home with his family, and there is currently one vacancy in the home. Another resident returned from Day Services later in the afternoon, and engaged the inspector in conversation about the things that preoccupied him, before going off to sleep in front of his own television. From the provides data set sent by the care manager to the commission prior to this inspection, it was established there fees in this home range from £325 a week to £860 a week. The home was warm and clean and tidy, with the men who were able to moving around the home as they pleased, and sensitive care and assistance being given to anybody not able to do this. Hospitality and helpful assistance was given by both staff and residents, and this report will not highlight anything of concern. What the service does well: What has improved since the last inspection? What they could do better: There will be no requirements or recommendations as a result of this should report. 1 Williams Street, DS0000008217.V319342.R01.S.doc Version 5.2 Page 6 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 Williams Street, DS0000008217.V319342.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 Williams Street, DS0000008217.V319342.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): 2. The outcome from this group of residents in this area was good. This judgment was made using all available evidence including a visit to the service. The home’s Statement of Purpose and Service User Guide was good, providing service users and prospective service users with details of the services the home provides, thus enabling an informed decision about admission to be made. EVIDENCE: The care manager reflected the updating of the statement of purpose in written evidence submitted prior to this inspection. This provided detailed information for prospective residents in sufficient detail to enable them to make an informed decision about the suitability of the service to meet their assess needs and expressed personal choices. The inspector examined a sample care plan during the afternoon, and this demonstrated that the gentleman in question had received a full multi disciplinary Community Care Assessment prior to admission to the home, and this had formed the basis for the production of his ongoing care plan within the 1 Williams Street, DS0000008217.V319342.R01.S.doc Version 5.2 Page 9 home, with regular reviews within the periods specified, and others to reflect any change in his circumstances. 1 Williams Street, DS0000008217.V319342.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. The outcome to this group of residents was good. This judgment was made using all the available evidence, including a visit to the service. This was based upon comprehensive personal care plans, and finding that residents had been assisted to make what decisions they were able to, and to take any risks that were appropriate. EVIDENCE: Evidence for this section was founded upon observation of and discussion with both the men who were resident in the home, and those people employed to care for them. This information was supplemented by an examination of the sample care plan, the views expressed on the relatives comments card, the outcome of a formal interview with a member of the care staff, and details recorded by the care manager in the provider dataset returned to the commission prior to the inspection. 1 Williams Street, DS0000008217.V319342.R01.S.doc Version 5.2 Page 11 Care planning was seen to cover the assessed needs of health and social care, as well as taking into account the expressed and observed preferences of the residents of the home. These had been reviewed at the minimum frequency recommended, as well as at any time when a change in circumstances had made it necessary to re-formulate the agreed mode of treatment, or of providing care. Where a risk had been identified, as in the case of a resident with inappropriate eating compulsion, or at risk from hot surfaces and liquids associated with cooking, the measures imposed had been the least restrictive possible to enable all residents to continue to live in safety, in the closest approximation to their wishes. The input of, and liaison with, appropriate health professionals from consultant psychiatrist through to occupational therapy assistant, was clearly evident. Help had been received from people specialising in speech and language, diet, continence, mobility, and aides and adaptations. Appointments had been made, and assistance had been given to enable and then receive input from the tertiary health care providers of dentistry, chiropody, eye care, and audiology. During discussion of a comment made in the previous report, the care manager was at pains to point out that with a particular individual, a balance had to be struck between championing his rights to have a holiday, and his distress when taken out of the security of his home even when this was only for a period of two hours. In this instance, the care manager made a very cogent case for the risk to the psychiatric well-being of his resident outweighing any possible benefit that someone with massive sensory deprivation would be able to obtain from receiving total care in another place or even in another country. Another example of the service providers being sensitive to managing the risks attendant on any individual in such a way as to maximise the outcome benefit for that resident, was seen in the contingency plans being made in case the home ever needed to be evacuated. Standby arrangements had been made with two separate taxi services to evacuate to other homes in the area run by the same provider, because the best interests of one resident would not be able to be met in the home that was closest to 1 William St, so therefore he would travel to a home slightly further away, but where the existing residents all had needs similar to his own. 1 Williams Street, DS0000008217.V319342.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, and 17. Quality in this outcome area, for this group of residents, was good. This judgement was made taking into account all evidence available, including a visit to the service, and because they are enabled to have a community presence, to be occupied or stimulated, to maintain affiliate links, and to be able to eat well. EVIDENCE: One of the first things to be observed when entering the home was a chart up on the wall behind the front door detailing the activities of each resident for a one-week period. As for the most part, these reflected the amount of support needed by most of three men to engage in outside leisure activities. One young man had a timetable dominated by his using a computer, some thing that he had become very proficient at, and something that enabled him to express interests in a tangible form that he had not previously found possible. 1 Williams Street, DS0000008217.V319342.R01.S.doc Version 5.2 Page 13 Another, and older, member of the house enjoyed frequent walks to a nearby municipal park, and having his hair cut at the barbers shop in the local community. These two men had enjoyed an overnight stay in a caravan in Wales, which had been donated to the providers by the family of a resident. The deputy manager had accompanied them. Other outings that the inspector was able to verify were day excursions to the new Trentham Village, and to Shrugborough Hall and gardens. The data set returned by the providers prior to the inspection lists Art, Cooking, Board games, Cards, Dominos, massage, sensory stimulation, music, TV, and videos, among the recreational and educational facilities and activities experienced inside the home, and shopping, local walks, the cinema, and trips to garden centres as leisure outings and day trips experienced outside the home. Whilst none of the current residents are in employment, the two youngest residents were attending day-care services, and had good contact on a regular basis with their families. From discussion with the manager, it became apparent that the older men were less fortunate, some having no family contact, and one maintaining the tie by letter. The care manager had stated that all residents were involved in everyday activities such as helping with cleaning, with the preparation of the meals, and with taking their worn clothes to the laundry when they needed to be washed. During the evening the delicious smell of the evening meal permeated the home, and on investigation it was found that one person who did not want a cooked meal was receiving salad for his tea. Care plans showed that dietetic advice had been sought for individuals, and that the special dietary needs of the gentlemen was known to the staff, and where concern about weight loss or weight gain was an issue, then regular monitoring of body mass index was recorded in the care plan. 1 Williams Street, DS0000008217.V319342.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): 18,19, and 20. Quality for residents in this outcome area was good. This judgment was arrived at using all the evidence available including a visit to the service, and was formed because residents were seen to receive comprehensive social and Healthcare support in line with their assessed needs and choices, and their programs had been reviewed regularly as demonstrated by the record in their personal care profiles. EVIDENCE: This service is specifically for people who have a learning disability, and in addition some of the current residents have physical disabilities that require the input of staff to assist them in their personal care. Those people who do not require direct assistance in washing and bathing benefit from close monitoring, and benefit from some form of assistance whilst taking their meals. 1 Williams Street, DS0000008217.V319342.R01.S.doc Version 5.2 Page 15 Three people have mental health needs other than their learning disability, four use wheelchairs, four require help when dressing and undressing, and currently all require assistance when washing or dressing. Two are visually impaired, and one person uses Makaton signing to help overcome his communication disability. From a sample care plan that was examined in detail, it was concluded that there was very thorough attention to the health care needs of the resident. This man had benefited from the annual Well Man Assessment in addition to input from his consultant psychiatrist, specialists in speech and language, the dietician, his GP, and domiciliary mental health and general nurses. Appointments to attend hospital, clinic, or GP surgery, had been made for him, and he had been assisted to attend to these. The tertiary Healthcare needs of his eyes, ears, feet and teeth had been covered by the input of regular appointments with the providers of these services. During the course of this inspection staff were observed to be interacting with the residents in a way that was only possible through detailed knowledge of their personalities and conditions. This was felt to be of paramount importance, as without such a close empathy for their residents, they would not have been able to promote emotional and physical health care needs, in the sensitive way that they were seen to be doing. The member of staff who was engaged in a formal interview described how the gentleman she assisted in the shower would undertake as much of the attention to his personal hygiene as he was able to, and how she would assist him in this, rather than doing it for him. One resident was enabled to take greater part in the daily routine of the home through the provision of a specially moulded wheelchair to support his frame, and another, who had been plagued for some time with a pressure sore on his heel, was benefiting from the input of specialist chiropody services and the district nurse, and had been provided with the supportive footwear of a Scotch Cast Boot, which in response to questioning he said: Oh yes, its very good, it makes walking much more comfortable. The care manager confirmed through the pre-inspection questionnaire that all members of staff were responsible for the administration of medication, and that an appropriate protocol and set of policies for the control, administration, self administration, recording, safekeeping, handling and disposal of medicines was in place. A member of staff who was an administering the medication during the inspection confirmed that she had received the training details in the provider data sets, and was observed to wash her hands before touching medication, to check the Medication Administration Record sheets before obtaining the correct dosage from the blister packs dispensed to the home by the nearby privately owned pharmacy. 1 Williams Street, DS0000008217.V319342.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): 22 and 23. The outcome for this group of residents was good. This judgment was made using all the available evidence including a visit to the service. It was based on staff being seen to be well trained, and sound policies and procedures had been in place to protect these vulnerable adults. EVIDENCE: established that she had received induction and refresher training to enable her to determine whether somebody was likely to be suffering from abuse, and what steps she should take to protect that person, and comply with the policy for the protection of vulnerable adults that had been agreed between all agencies. She knew who the vulnerable residents of this home were at risk from, and was able to enumerate many forms of things that is done to, or withheld from a person, would constitute an abuse. The complaint procedure was provided in a user-friendly format and was also included in the service users guide as well has been displayed on a wall in the main area of the home. No complaints had been received about this service by the commission, and the care manager was able to report that none had been made directly to the home during the period since the last inspection either. 1 Williams Street, DS0000008217.V319342.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, and 30. The outcome for this group of residents was good. This judgment was reached using all the evidence available including a visit to the service and was made as the residents were seen to be living in a homely, comfortable, and safe environment, with personal and communal space that met their needs and lifestyle, and helped to promote their independence, in an environment that was well maintained, clean, and hygienic. EVIDENCE: 1 William St was purpose built to provide the service which it now offers. Being single storey through out, it has no access problems, and whilst not totally in keeping with the other buildings around it (which are mainly twostorey terraced buildings), is not stigmatised as being a care home. A cursory visual examination of the exterior did not detect anything in need of attention, and the interior presented as being equally well maintained and well decorated. 1 Williams Street, DS0000008217.V319342.R01.S.doc Version 5.2 Page 18 All bedrooms are for single occupation, and whilst fitted with individual washbasins, none had separate ensuite toilet facilities. Not all bedrooms were visited during this inspection, but those that were displayed the differing tastes and interests of the men living in them, and were comfortably furnished and well decorated. They were light and airy, and in one room to which the inspector had been invited by the resident, there was memorabilia of his favourite local football team, and a computer on which he spent much of his time, when not attending Day Services, or visiting his family. The shower room was of good size and adequately functional, but the real star of the home was the spacious bathroom where much attention and equipment had gone into providing a sensory experience that could be enjoyed by even the most sensory deprived resident. The ratio of one toilet to every three residents was met, and handrails were provided around the home and were of the substantial tubular type, affording maximum assistance to any resident with poor mobility. A decorative gate had been fitted between the kitchen and the dining room, and a temporary coded lock was being used in connection with ensuring the safety of one resident at risk from choking if able to access to unsupervised. Discussion took place with the care manager who assured the inspector that work was in progress to fit this with a type of lock acceptable to the fire officer, and linked in to the fire alarm system of the home. The lounge which adjoins the dining room was spacious and comfortably furnished, and during this visit two residents were being entertained by programs of a television of sufficient size to make viewing easier for the visually impaired. Externally, there was a secluded rear garden with patio area, and a driveway at the front where a maximum of four cars could be parked off street . 1 Williams Street, DS0000008217.V319342.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. The outcome for this group of residents was good. This judgment was made using all evidence available including a visit to the service. It reflects an adequate staff-to-resident ratio, and there being sufficient and appropriate training of, and employment of, experienced and qualified staff. EVIDENCE: A member of staff was engaged in a formal interview during which she confirmed the statements of the care manager in the pre-inspection questionnaire that staff are required to have the competencies and qualities necessary to meet the needs and personal choices of the residents of this home. It was confirmed both by herself at this time, and by examination of her own personal care records kept in the home, that the people she had named as referees had been approached to make written comments about her suitability for the post, and she had not had anything recorded against her by the Criminal Records Bureau. 1 Williams Street, DS0000008217.V319342.R01.S.doc Version 5.2 Page 20 She said that she had seen the position initially in the local newspaper, and that her recruitment had seemed to her to comply with equal opportunities and diversity good practice, and equal opportunities and employment law. She was able to give personal testimony to staff meetings being held, and to the openness of the supervision arrangements. Of the nine care staff employed in this home 55 are trained to NVQ level 2 or above, and like the care manager they all hold current first aid certificates and have been trained to administer medication. From having a full staff complement in February this year, the home is now in a position where they have three vacancies; two members of staff have been transferred to other homes, and one being on maternity leave. The discrepancy is being made up by use of bank staff, and one lady who was previously employed full-time in another Choices home nearby covers the majority of the hours. 1 Williams Street, DS0000008217.V319342.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. The outcome for this group of residents was good. This judgment was based on all the evidence available including a visit to the service. The manager was felt to be competent in all he did, and ran the home following the best principles of current thinking in good practice for people with learning disability. The records showed that the maintenance of the home had been appropriately undertaken, and that measures aimed at maximising the health and safety of all those in the home had been completed both spontaneously, and in line with the minimum intervals recommended. EVIDENCE: Information in the pre-inspection questionnaire indicated that all equipment in the home had been serviced at the appropriate intervals in the period since the 1 Williams Street, DS0000008217.V319342.R01.S.doc Version 5.2 Page 22 last inspection, and the policies and procedures required by regulation were in place and regularly reviewed. Records showed that the fire alarms were tested each week, and that emergency lighting was also checked on a regular basis, and that there was servicing of the fire equipment and training of staff in what to do in case of a fire. There were also regular drills and simulations, and in discussion with the inspector, the care manager stated that to the best of his knowledge the only outstanding issues from the fire officers report was the completion of the individual evacuation plans, and what is called the Total Devastation Plan. In the care plans looked out during the afternoon, there were a risk assessments appropriately carried out to maximise the health and safety of residents living in the home. The care manager, Mr Richardson, in addition to being a first level nurse who has managed the service for approximately 13 years, completed his care manager’s award last year. (His deputy commenced her study for this award in September this year.) The providers regularly send copies of the monthly quality monitoring visit reports from their Principle Officers to the commission, and these provide a firm foundation for assessing how the service is meeting the needs of its users, as one of the standard components of this process is talking to residents and gathering their views. 1 Williams Street, DS0000008217.V319342.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No Score 6 4 7 3 8 X 9 3 10 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 4 25 X 26 3 27 3 28 3 29 X 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 3 X X 4 X 1 Williams Street, DS0000008217.V319342.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. 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 Williams Street, DS0000008217.V319342.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Williams Street, DS0000008217.V319342.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. 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