Inspection on 18/04/06 for 103 Cliddesden Road

This inspection was carried out on 18th April 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

103 Cliddesden Road 29/08/07

103 Cliddesden Road 16/01/06

103 Cliddesden Road 22/10/04

103 Cliddesden Road 26/05/04

103 Cliddesden Road 28/01/04

103 Cliddesden Road 11/02/03

Similar services:

21 High Street

Vale House

Chestnut Walk

The Old Vicarage

Cherwood House Care Centre

Ashley House

Ascot Nursing Home

Fountain View

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

CARE HOME ADULTS 18-65 103 Cliddesden Road Basingstoke Hampshire RG21 3EY Lead Inspector Annie Billings Unannounced Inspection 18th April 2006 10:00 103 Cliddesden Road DS0000012308.V289463.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 103 Cliddesden Road DS0000012308.V289463.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. 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 103 Cliddesden Road Address Basingstoke Hampshire RG21 3EY 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) 01256 333423 www.together-uk.org Together Working for Wellbeing Mrs A Redford Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16TH January 2006 Brief Description of the Service: 103 Cliddesden Road is a three-storey home set in a quiet residential area in Basingstoke, opposite one of the local colleges. It is within easy reach of the town centre and easily accessible by road, rail and other transport networks. The home is registered to provide care and accommodation to seven service users who have mental health issues. The home comprises of seven single bedrooms, one sitting room, dining room, kitchen, a quiet room and laundry facilities. There is also a rear garden and patio area, providing additional recreational space. A small parking area is available at the front of the property. 103 Cliddesden Road encourages service users to retain their own privacy and is pro-active in supporting people to move towards more independent living. The manager advised the current weekly fee level of £726. This fee does not cover personal toiletries or hairdressing. Copies of the statement of purpose and service user guide are available in the entrance hall, and are given or sent to a prospective service user. The guide states that copies of inspection reports are available on request. Opportunities are offered to visit the service to view the accommodation, meet staff and residents before deciding whether to move in. 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four hours plus an additional visit on the 21st April for a further two hours, to look at staff records and hold discussions with the acting manager. An opportunity was taken to look around parts of the home, view some records and talk to two staff, one service user, the acting manager and a visiting community psychiatric nurse. On the day of the visit there was only one service user accommodated. All of the core standards were assessed during these visits, and three previous issues identified at the last inspection were followed up. The registered manager and two members of the staff team have not worked at the service since November 2005, as the organisation is conducting some enquiries. The service is currently managed by an acting manager and staffed by the remainder of the staff team with additional support from seconded staff members from other services within the organisation, to ensure appropriate staffing levels are maintained. What the service does well: What has improved since the last inspection? Routines in the home have become more flexible to reflect the resident’s needs and wishes. Residents are much more involved and consulted about the running of the service, and there is evidence that views are listened to and 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 6 changes made. One resident commented that the service is “much more like home” following the changes in management and staff team. Resident’s files have been reorganised to ensure that information remains consistent, current and accessible. Three monthly reviews have been undertaken, and short-term care plans produced to ensure that staff have sufficient guidance to meet people’s needs. Staff have a good understanding of the adult protection issues. Following the last inspection, all staff have attended training in adult protection. Since the last inspection repairs have been completed to a lock on one bedroom door to ensure the privacy of the resident, and medication storage is now lockable in one residents’ room. What they could do better: Detailed assessments must be undertaken prior to admission, to ensure that the home can meet the prospective resident’s needs. Actions by residents or staff to support care plans must be recorded, to enable progress to be measured. Monitoring of bathrooms must be undertaken to ensure they remain clean and hygienic. Update training of staff must be undertaken promptly to ensure that staff are aware of best practice. Maintenance and fire records must be kept up to date. The manager has agreed to take action or has already taken action to address all these issues. The kitchen and lounge doors must be fitted with automatic closures to ensure the safety of residents and staff. This is an issue from the last inspection, although the timescale given has not been reached and the manager is aware this needs to be completed by the 16.7.06. Major plumbing work must be undertaken promptly and repairs and decoration undertaken, to ensure the home is well maintained. The housing association have accepted responsibility for this, and the organisation is meeting with the association to set a date for work to commence. 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality rating of this outcome section is poor. This judgement has been made using available evidence including a visit to the service. Needs have been assessed as part of an interim review process. Although this ensures that basic needs are addressed residents cannot be assured that there long terms objectives will be achieved. EVIDENCE: No new admissions have been made to the home since the last inspection; therefore the pre-admission process has yet to be tested. The acting manager advised that no assessments were available for existing residents, although plans to adopt the “recovery” care model would include reassessment as part of that process. The development of this process has been delayed until the staff and management team stabilises, although training for staff has begun. As an interim measure, three monthly reviews have been undertaken by the link workers to ensure that needs continue to be met, but these remain basic, and do not take into account people’s long-term objectives or develop strategies to meet these goals. Risk assessments have been reviewed and updated, and resident’s files reorganised to ensure that information remains current and historical information is archived. 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The quality rating of this outcome section is adequate. This judgement has been made using available evidence including a visit to the service. Interim care planning arrangements ensure that service user’s needs are met, although further development of this process must be made to ensure that long term objectives are clearly identified, and progress monitored. Procedures are in place to ensure service users are supported to make decisions and enabled to take risks as part of an independent lifestyle. EVIDENCE: Good progress has been made in updating and reorganising resident’s files, to ensure they are clear and up to date. One link worker is currently working with a resident in developing a life map. Short-term care plans are in place for the remaining two residents. These were sampled, and provide staff with sufficient guidance on how to meet people’s needs. Actions to be taken by staff, identified within the care plans, could not be evidenced. This makes it difficult to measure how successful the care plan is in meeting the objectives set. The manager agreed to develop this area, and further improve recording 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 11 procedures. Two staff spoken with had a good understanding of the residents support needs. Discussion with the acting manager identified future plans to further develop the care planning process by adopting the “recovery plan” model of care. Staff said they have commenced training in this area, but development has been delayed until the staff team have stabilised. The model of care sampled puts the individual at the centre of the process, sets long and short-term objectives and allows them to drive the process forward. Discussion with one resident confirmed they had been involved in the review process, and had signed their agreement to the care plan. They confirmed they make daily choices, and decide their own daily routines, as observed. The resident felt they are well supported, particularly by the current staff and management team. They meet regularly with their link-worker, and said that staff are always around to offer advice and support when necessary. Any areas of risk identified are supported by risk assessments. These were sampled, and recent reviews were available. Any agreements reached by individuals in support of their care plan have been supported by written consent of all parties concerned. A discussion with the resident’s community psychiatric nurse (CPN) further confirmed that the resident is well supported, and the service meets their needs. Any issues are communicated promptly by staff and management. 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 The quality rating of this outcome section is good. This judgement has been made using available evidence including a visit to the service. Activities, relationships and diet are well managed, promoting choice and independence for service users. EVIDENCE: Discussion with one resident confirmed they make their own choices in respect of activities and accessing the community, and was seen to come and go as they pleased without restriction. Group activity is difficult at present, with only one resident currently accommodated, although the manager advised that previous residents are encouraged to visit the service, and evening meals out were being organised as a result of a suggestion made by residents at the last meeting. The resident confirmed they decide on their own daily routine. This was observed during the visit, getting up when they wished, making drinks and undertaking their own cleaning responsibilities. They said that staff treat them 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 13 with respect, and since the last inspection had fixed the door lock on their bedroom door, to ensure their privacy. Interaction seen between staff and the resident was respectful and their right to privacy was promoted. Records seen confirmed that family members and visitors are encouraged to remain in contact with residents. This was discussed with one resident, who confirmed that the home’s policy is flexible, and visitors are welcomed. The resident said they are self-caring, which means the home provides the money and the service user shops, prepares and cooks their own food. They each have their own cupboard to store their food and a compartment in the freezer, in addition to their own fridge. Service users are encouraged to record the food they have eaten on a daily basis, to allow monitoring by staff if it appears service users are starting to neglect their diet, particularly with one resident who is on a self-imposed diet. Staff advised this would be discussed at the weekly link worker meetings. 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The quality rating of this outcome section is good: Systems are in place to ensure that personal care, health and medication are well managed, and independence promoted. EVIDENCE: Two service user’s plans were sampled, although one was not currently accommodated in the home. These contained information on each service user’s specific needs. The one resident spoken with confirmed they are able to manage their own personal care, and could access the local health care team as and when necessary. Staff are on hand to offer advice, and one staff member confirmed they had encouraged the resident to consult with their GP around their diet. The resident confirmed they are able to self medicate, and has a lockable storage area available in their room. A written agreement to this was seen on file. Other records seen were well maintained, and stocks checked in line with the home’s policy. The medication of a previous resident was found stored in the medication cupboard. The resident had moved out over three months ago, and the home was reminded to ensure that returns are made to the pharmacy promptly. This had been addressed before the second visit. 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 15 All staff receive training in the safe handling of medication, and are currently undertaking a distance learning course by a local college. 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Arrangements for protecting service users and responding to concerns are satisfactory. EVIDENCE: Discussion with one resident confirmed they feel the current staff and management team listen to them and take appropriate action. They had a good awareness of the procedure, knew who to talk to, and felt that any concerns would be addressed. The manager confirmed there had been no complaints received since the previous inspection. As a result of a previous allegation of abuse, issues relating to care and management practice were raised. These are currently being investigated by the organisation, who is keeping the commission fully informed of progress. Staff advised they had received training in adult protection in March 2006, as a result of the last inspection. Discussion with two staff members identified a good understanding of the reporting procedures. Training records seen confirmed that all staff had attended the training course. 103 Cliddesden Road DS0000012308.V289463.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 The quality rating of this outcome section is adequate: The accommodation meets the needs of the residents, although delays in refurbishment of some areas do not ensure the premises remain well presented or well maintained. The need to upgrade fire door closures may compromise the safety of service users and staff if not addressed promptly. Additional monitoring of bathrooms is necessary to ensure the premises remain clean and hygienic. EVIDENCE: The layout and location of the accommodation is suited to the resident’s needs. One resident confirmed they are happy and comfortable in the home, and feels their room meets their needs, although the home was cold in the winter, and they had problems with their radiator, this has since been repaired. They further advised that the lock on their bedroom door had been repaired following the last inspection. Communal rooms are decorated to a reasonable standard, and appear comfortable and homely. A partial tour of the premises identified water damage to the ceiling in the utility room. Issues with the plumbing in the home have been ongoing, and discussions with staff, the manager and the area manager of the service 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 18 confirmed that major work is due to be undertaken by the housing association. Although aware of previous problems with heating and hot water, the resident advised that they had not been affected recently. Originally planned for March of this year, this has subsequently been delayed and the organisation is meeting with the association in early May to determine the date for work to commence, as this will necessitate the home closing for a period of time. Because of this major work, the rolling programme of decoration and refurbishment has been put on hold until this work is completed. A number of carpets are badly stained and need deep cleaning or replacement. Staff also advised that the vacuum cleaner was not working effectively, and the home was to purchase another. The majority of the home was clean and hygienic, although two bathrooms were in need of cleaning. Residents take responsibility for cleaning, and following discussions with the manager, it was agreed that future weekly monitoring of resident’s rooms would include bathrooms, to ensure they remain clean and hygienic. This issue had already been addressed by the second visit. The manager also agreed at the last inspection to provide paper towels in bathrooms and WC’s, to improve infection control practice. This has yet to be completed, although the manager agreed to put these in place. Fire doors were again propped open to the lounge and kitchen. This was discussed at the last inspection and a requirement made to fit automatic closures. The manager advised they had consulted with the housing association, and no agreement had been reached so far, although the manager is aware of the timescale given for compliance with the requirement. In the interim the manager and staff must ensure that fire safety is not compromised by wedging fire doors open. As a result of discussion at the last inspection, risk assessments have been undertaken in respect of the need for window restrictors, which has led to all restrictors being removed as no risk was identified. 103 Cliddesden Road DS0000012308.V289463.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 The quality rating of this outcome section is adequate: Residents are supported by a good skill mix workforce, and are well trained and supervised, although training updates must be provided promptly to ensure that staff are aware of best practice. Recruitment practices ensure the protection of residents. EVIDENCE: Training records are currently being updated, although certificates on file confirmed that staff have undertaken a variety of training courses including dual diagnosis and criminal justice, working with forensic – mental health needs and non violent crisis intervention. Several staff members have already completed National Vocational Qualification training, and the manager confirmed that more staff were to be registered. Three staff files sampled confirm that thorough pre employment checks are undertaken prior to employment, including a criminal records bureau check, to ensure that staff are suitable to support the residents. One resident advised that other residents had been involved in the recruitment process, sometimes being included in the interview panel, and was aware of training provided by the organisation to encourage people to undertake this role. Staff spoken with confirmed that training is plentiful and accessible, although discussion with a new staff member identified delays in accessing the organisation’s induction training programme, although an in-house induction 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 20 had been given. Records of this were incomplete, although the manager advised that the staff member had worked in the home as an agency worker for a considerable period prior to this. Employed since December, the induction programme was not available until the end of April. The member of staff advised this also delays access to other training courses until this programme is completed. This issue has been raised previously with the organisation, who are looking at ways of making the programme more accessible. Staff advised that training needs are discussed at monthly supervisions. Records sampled confirm this, although a number of mandatory training updates were identified as long overdue. Evidence was available to support the manager was addressing this issue, and updating of training records was already underway with other dates booked into the diary, therefore no requirement was made. Two members of staff said they felt well supported by management, although recent events and changes in management and staff had left one member of staff feeling unsettled. One resident said they feel staff have the necessary skills to support them, and are always available for advice. 103 Cliddesden Road DS0000012308.V289463.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 adequate. This judgement has been made using available evidence including a visit to the service. The current management approach is effective in improving outcomes for residents, ensuring the service development is informed by their views. Health & safety are generally managed adequately although wedging open fire doors compromises the safety of staff and residents. The service must ensure that health and safety records are updated regularly. EVIDENCE: One resident said that recent changes in the management and staff team have led to changes in routines in the home, saying, “it feels more like home”. They felt encouraged to voice their opinions to their link worker or manager, and that they would be listened to and action taken. This was confirmed through sampling of resident meeting minutes. The acting manager is a registered manager for another service within the organisation, and according to comments made by staff gives a clear direction 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 22 to the service. Staff felt they are well supervised and supported, although one felt a little unsettled following changes within the staff team and management. It was clear from comments made by one resident and staff, and from observation during the visit that residents and staff benefit from the leadership and management approach of the home. The organisation has an internal quality audit system, and on a monthly basis seeks the views of service users. These are reviewed on an annual basis. The area manager visits the home monthly and makes themselves available to service users wishing to discuss any aspects of their care. A visiting CPN also confirmed that the resident was kept fully informed about the recent changes to the staff team, and with regard to plumbing work due to be undertaken in the home. Staff spoken to had an awareness of health and safety policies and procedures in the home and where to access them, and had received appropriate training, although records seen identified the need to update these, as recent fire training had not been recorded. A new maintenance log had been developed, and entries had not been made to confirm that action had been taken. The manager agreed to follow this up with the person responsible. Procedures are in place to ensure that the environment, and systems used in the home remain safe, although wedging open fire doors compromises the safety of both staff and residents. These had been removed by the second visit to the home. Risk assessments are undertaken on a regular basis to determine any actions that need to be taken to minimise risk to staff and residents. It was noted that the home did not have a food probe, to ensure that food is served at a safe temperature. This was already in place by the second visit, and residents were to be encouraged in its’ use to reduce any risk of food poisoning. 103 Cliddesden Road DS0000012308.V289463.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 2 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23(4)(a) Requirement The registered person must ensure there are automatic fire closures on the kitchen door and lounge door and that fire doors must not be wedged open. This requirement was made following the last inspection, and is repeated, as the timescale has not expired. Timescale for action 16/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 103 Cliddesden Road DS0000012308.V289463.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton 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 103 Cliddesden Road DS0000012308.V289463.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!