Inspection on 24/10/06 for 122 Green Lane

This inspection was carried out on 24th October 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

122 Green Lane 23/08/07

122 Green Lane 25/04/06

Similar services:

Belle Vue Country House

Crossways Community

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

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

CARE HOME ADULTS 18-65 Green Lane (122) 122 Green Lane Addlestone Surrey KT15 2TE Lead Inspector Mary Williamson Key Unannounced Inspection 24th October 2006 10:00 Green Lane (122) DS0000066920.V317510.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 Green Lane (122) DS0000066920.V317510.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. Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Green Lane (122) Address 122 Green Lane Addlestone Surrey KT15 2TE 01372 722970 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.together-uk.org Together Working for Wellbeing To Be Confirmed Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th April 2006 Brief Description of the Service: Green Lane is a substantial converted property providing accommodation and nursing care for twelve service users with a mental health disorder. Welmede Housing Association formally owned the home. It has recently changed ownership and was registered on 1st April 2006 with Together as the new providers. The home is located in the village of Addlestone within easy access to the local shops and facilities. The accommodation is provided in single en-suite rooms. There is ample communal space, which includes a dining room, and two lounge areas one of which is used as a smoking area. There is a large garden accessible to the service users situated to the side of the building. There is also ample parking facilities at the front of the home. Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second key inspection undertaken at the 122 Green Lane this year. This inspection was part of a Pilot Scheme currently being undertaken in the South East Region focusing on mental health services. Mary Williamson who is the lead inspector for the service undertook the inspection. Tina Coldham who is an expert by experience accompanied the inspector for part of the inspection. Sharon Imbrey acting deputy manager was present throughout the inspection. CSCI are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We are currently testing a method of working where ‘experts by experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term ‘expert by experience’ used in this report describes people whose knowledge about social care services comes directly from using them. Both the inspector and the expert by experience had the opportunity on several occasions throughout the day to talk with service users either individually or in groups. They also had lunch with the service users. It has been six months since the new providers Together have taken over the provision of the service and the service users are gradually continuing to gain confidence in the new systems and structure within the home. The expert by experience undertook a tour of the premises and had the opportunity to view some service users rooms on invite. She also spent time talking to staff, observing interaction amongst service users and gaining feedback on their experiences of living in Green Lane. She explored the opportunity available for leisure and recreational activities, which highlighted shortfalls and need for improvement. The inspector examined records relating to the care of the service users and the management of the home, including needs assessments, risk assessments, care plans, medication recording charts, menus, staff duty rota, employment records, training records and a wide range of policies and procedures. The inspector and the expert by experience would like to thank the service users, and the staff team for their help and positive approach to the inspection process. What the service does well: Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 6 The manager and staff team provide ongoing care and support for twelve service users in an environment, which continues to develop both physically and administratively. The standard of record keeping is good with the deputy manager working towards improving person centred planning, updating the assessment process and evaluating outcomes of care on a regular basis. There is a relaxed and pleasant atmosphere between service users and staff. There is a very good care reviewing process in place with the multidisciplinary team attending weekly reviews in the home. The expert by experience was very impressed by this. There is good communication between staff, which includes comprehensive shift handovers. Staff keep good written records of events, which effect the wellbeing of service users. What has improved since the last inspection? Since the last inspection the service manager has submitted an improvement plan to The Commission for Social Care Inspection outlining how the requirements made were being met. While some of these requirements have been met others have been highlighted as long term projects or incorporated in the budget for the next financial year. The statement of purpose has been rewritten and available to all the service users. The care plans are in the process of being reviewed and new person centred plans written with the service user have been introduced. The home has now produced a policy for the administration of medication. The management team has worked hard to improve the environmental standards of the home. The reception area has been made more welcoming. The dining room has been refurnished with good quality furniture and is a non smoking room. There is now a cleaner in post and he must be commended on the muchimproved standard of cleanliness and hygiene throughout the home. There is also a cook in post who manages the catering arrangement in the home. This has now provided more care time as the care team were previously undertaking this task. Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 7 What they could do better: One service user stated that he would like to read the published reports on the home. A copy of the most recent report must be included in the statement of purpose and made available to service users. Sufficient staff must be available to motivate service users to participate in social and leisure activities. During conversations with the expert by experience and the inspector service users expressed on several occasions that they wished for more activities both within the home and in the wider community. Several service users told the expert by experience that they missed the home’s transport and going out on group trips. Provision must be made to reinstate these trips. One service user stated that he wanted to have regular service user meetings where the service users took the lead and the staff just observed. During a conversation with the cook the expert by experience discovered that the shopping is done early morning and that the service users are not involved in this task. A suggestion was made that maybe this could be included in group activities. They also stated that there should have been more BBQ’s during the summer. There is a large garden and one service user had a vegetable patch, which was now overgrown. He expressed to the expert by experience his desire to recommence this project at his pace with staff supervision. This must be explored. The large lounge, which is also the smoking room, must have a more efficient extractor fan. This room is also very dark and needs repainting and ceiling lights fitted. The expert by experience also observed various ceiling tiles throughout the home stained by water leakage and must be replaced. The organisation must submit an application to The Commission for Social Care Inspection Central Registration Team in London for the manager to become registered. Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 8 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. Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 9 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 Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 10 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): 1, 2, and 5. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. A new statement of purpose and service user guide is available to all service users. Needs assessments and contracts of occupancy are in place. EVIDENCE: The statement of purpose and service users guide has been rewritten since the home was reregistered in April 2006. All service users have access to a copy of this, and there is also a copy available in the main reception area. One service user stated that while he was in favour of inspections he never got to read the inspection reports. The acting deputy manager stated that she would make this report available to the service users and that it would be included in the statement of purpose in the reception area. Individual needs assessments are in place which are in the process of being updated. The service users at Green Lane have been living there for several years and there have been no recent admissions to the home. The acting deputy manager demonstrated the new assessment format being introduced to bring all information up to date. Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 11 Contracts of occupancy are in place and are signed by service users. One copy is given to the service user and the second copy retained on file. These contracts outline the fees paid and by whom and the accommodation and care to be provided. Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 12 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, 8, 9, and 10.Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Individual care plans outline service users needs and goals, which also include risk assessments. Information relating to service users is treated in confidence. EVIDENCE: Individual care plans are in place, which are in the process of being rewritten. This is to update the plans from the old NHS model to the new format based on the aims and objectives of “Together”. The acting deputy manager explained the new process of care planning called person centred planning. She demonstrated the new assessment process involving the service user, identifying strengths and needs of individuals, and the process of reviewing these. The service users sign care plans. Risk assessments are in place and these are also in the process of being updated. These assessments are undertaken based on a risk assessment tool, Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 13 and a risk management tool. These assessments are not restrictive but are safety orientated. Service users are given the opportunity to participate in the daily running of the home. From observation some service users require more support and encouragement to achieve this. For example involving service users to plan menus and help prepare meals. K stated that house meetings are infrequent. He also said that he would like to see these meetings chaired by the service users with staff observation. Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 14 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, 14, 15, and 17.Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. The majority of service users lack the enthusiasm to take part in appropriate leisure or community activities. Family links are maintained and nutritional needs of the service users are met. EVIDENCE: The expert by experience had the opportunity to talk with service users throughout the day. More than one service user made the comment about the lack of transport available to them and that they missed the mini bus and their trips out as a group. There is a lack of public transport and service users are reliant on staff taking them out in their own cars on odd occasions. The expert by experience also noted the lack of daily newspapers, and other reading materials to include books, magazines, brochures and catalogues. One service user told the inspector that she goes to a drop in club one day a week where she enjoys the social contact. She used also attend a computer class which has now been discontinued. Another service user stated that he Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 15 attends a day centre three days a week but had not gone on the day of the inspection as he overslept. There is a golf club nearby where some service users go for coffee or a drink. One service user told the expert by experience that there was a selection of local sops where he can buy cigarettes and take away food. In house activities are limited and two service users stated that she would like to have bingo sessions start again as they liked the prizes. K stated that he would like to see an art group start in the home. Although he would not want to take responsibility for this he would be willing to help and support fellow service users. There is potential for the large garden to be utilised more and one service user told the expert by experience that he liked to grow produce but the staff should recognise the level of support and time he requires. Family links are maintained. J stated that she had been on a holiday with her brothers to Dorset and A stated that he had also been on a holiday with his mother. Visitors are welcome in the home at any reasonable time and relatives are encouraged to attend care reviews. A relative steering group meet regularly and are actively involved in events within the home. They have the support of the PCT and consultant input. Since the last inspection there is now a cook in post. Menus are displayed in the kitchen, which are planned by the cook. It was difficult for the expert by experience or the inspector to determine how much service user involvement there is in menu planning, as there were conflicting statements from service users. Generally the food offered was wholesome and nutritious. Service users are supported to follow a healthy living plan to monitor weight gain and vitamin deficiency as side effects of taking long term psychiatric medication. One service stated that the food was good and another stated that the food was boring. During a conversation with the expert by experience the cook stated that she goes shopping very early in the morning to beat the rush and gain provisions easily. Both the inspector and the expert by experience felt that maybe this could be incorporated into a daily activity for service users. It was good to note that the newly refitted kitchen encourages service users to be more independent in making drinks throughout the day. However one service user told the expert by experience that the kitchen is not assessable during the night. The acting deputy manager was going to explore this statement. The kitchen is clean and orderly and all the necessary records relating to Environmental Health regulations are in place and are well maintained. Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 16 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 in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Service users personal, health, and medication needs are met as outlined in individual care plans. EVIDENCE: Sensitive support is offered to service users by staff as outlined in individual care plans. The acting deputy manager demonstrated the new health action plans, which are being introduced. These include support for service users who want to stop smoking and to loose weight. It was very encouraging to note that one service user has now managed to stop smoking. All the service users are registered with a local GP. She was visiting the home during the inspection and there was the opportunity to talk with her regarding the level of support she provides. Currently she attends the home with the psychiatrist every Tuesday afternoon to review service users wellbeing including a review of medication. This enables all service users to have a review every three months. On discussion with some service users they felt supported by this system and two service users stated that they could talk to Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 17 the doctor about their medication regime and any difficulties they have regarding their mental wellbeing. Dental treatment is provided at Goldsworth Park NHS Dental Surgery, or at Ashford Hospital if a general anaesthetic is required. Chiropody treatment is available every three months and the optician can be visited in the town centre. The home has a medication policy in place, which has been updated since the last inspection. Medication recording charts were sampled and are well maintained, some of which were being reviewed by the GP. Medication is supplied by Lloyds the Chemist in blister packs. They also undertake regular audits. Qualified staff only undertake the administration of medication. Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 18 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. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The complaints and abuse awareness procedures protect the service e users in the home. EVIDENCE: The home has a complaints procedure in place and all the service users have access to a copy of this procedure. There is also a copy available in the reception area. There has been one complaint made against the home since the last inspection, which has now been resolved. The Commission for Social Care Inspection must be informed of formal complaints received in the home by a regulation 37notification. There is also an abuse awareness procedure in place and all staff have training in this during their induction training programme. The home also has a copy of Surreys Multi Agency Policies and Procedures on Safeguarding Vulnerable Adults and all senior staff have undertaken training in these policies, which has been cascaded throughout the staff team. There has been one occasion where these policies have implemented effectively since the last inspection. Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 19 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, 25, 28, and 30. Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. The home is improving and working to promote a comfortable and safe environment for service users. The standard of cleanliness is good. EVIDENCE: The home was clean and hygienic. There is a new cleaner in post and he must be commended on the improved standard of cleanliness throughout the home. The entrance hall has been furnished with a long table accommodating fresh flowers a visitor’s book and a copy of the homes statement of purpose, which makes the home feel more homely. It was very encouraging to note the new dining room facilities, which promoted comfort and enhances service users meal times. The expert by experience and the inspector had the opportunity to have lunch in the dining room with some of the service users who all had positive feedback on the improvements. Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 20 The expert by experience noted that the non- smoking lounge was very pleasant. The large smoking lounge was rather dark and smoky, even with the door and some windows open. The extractor fan is not powerful enough to cope with the smoke. Some of the ceiling tiles throughout the home are heavily stained from water leakage and need to be repaired. The windows throughout the building need to be repaired and repainted. This was a requirement from the last inspection and the service manager in an improvement plan outlined that this would be undertaken in the spring when the weather improves. The exterior of the home also needs painting. The expert by experience had the opportunity to view some service users bedrooms, which had been decorated to individual choice, and had been personalised. The inspector observed that the standard of individual accommodation varied and that some service users required more support to maintain their individual space. There are ample bathrooms and toilets situated throughout the home. Consideration should be given to providing some assisted bathing facilities when bathrooms are due for refurbishment. This will address the changing physical and mobility needs of some service users. Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, and 35. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The current staff team is sufficient to meet the physical need of the service users. The recruitment procedures protect the service users and staff training is ongoing. EVIDENCE: The staff duty rota was seen. This indicated three care staff, one cleaner and one cook work in the home during the morning shift, three carer staff work the afternoon/ evening shift and there are two members of staff on duty during the night. There is a qualified nurse on duty twenty fours a day. In view of the service users comments regarding lack of activities and direct observation both from the inspector and expert by experience the ratio of staff per shift does not meet the holistic needs of service users. The acting deputy manager stated that the need for an activities coordinator had been recognised by the management team and that twenty hours a week was being allocated for this post. The acting deputy manager stated that four new staff had been recruited to work in the home and will commence employment when all the administration procedures have been completed. Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 22 One service user told the expert by experience that there are too many bank staff used in the home. The organisation has a recruitment policy in place, which protects the service users. The employment files contained all the required documentation including CRB (Criminal Records Bureau) disclosures. Together are committed to staff training and development. All staff undertake induction training. The organisation is an assessment centre for NVQ training and there are three assessors within the home. NVQ training is ongoing with several staff having achieved Level 2 and Level 3 awards in care. Currently there are two staff undertaking NVQ Level 2. Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, and 42 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The home is well managed and the health and safety of service users are promoted. EVIDENCE: The manager was on leave and the acting deputy manager was managing the home in his absence. She has been working in the home for three months having been transferred from another project within the organisation. The home was functioning well and several service users stated that they felt secure with the new management structure within the home. It was reassuring to hear these comments as there had been a long period when the service users were unsettled during the transition to Together. Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 24 The acting deputy manager stated that the home encourages an open door style of management. There is whistle blowing policy, and a no secrets policy in place. Quality assurance is monitored by monthly visits undertaken by the service manager and recorded as regulation 26 visits. Yearly feedback surveys are undertaken by service users, relatives, staff, and visiting professionals. The standard of record keeping is good. Records seen included care plans, risk assessments, medication recording charts, staff training records, and staff recruitment procedures which were all well maintained. There had been a complaint made within the service since the last inspection, which had not been reported to The Commission for Social Care Inspection under Regulation 37 procedures. There is a wide range of health and safety policies and procedures in place and training is ongoing in these procedures. These include risk assessing, first aid, fire safety, food hygiene, manual handling, and COSHH. The fire safety records were seen and are well maintained. Comprehensive risk assessments are in place for smoking related risks. There is a contract in place for the maintenance of fire fighting equipment and emergency lighting. The expert by experience noted a smoke detector had bee disconnected on the first floor but on further investigation this was not connected to the main fire alarm system. The acting deputy manager stated that she would have this removed immediately. Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 3 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 3 26 X 27 3 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 2 3 3 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 2 3 X Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5(2) Requirement The registered person shall provide a copy of the most recent inspection report within the statement of purpose and make this available to all service users. The registered person shall enable service users to make decisions with regard to the care they receive and the daily involvement in the home. The registered person must consult with service users about their programme of activities and make arrangements to enable them to engage in activities Timescale for action 03/12/06 2. YA7 YA8 12(2) 03/12/06 3. YA12 YA13 YA14 16(2)(m) 03/12/06 4 YA24 YA28 23(2)(b) The registered person must 03/12/06 ensure that all parts of the care home are kept in a good state of repair both externally and internally to include the repair and repainting of the windows, painting the exterior of the building, redecorating identified bedrooms, and replacing ceiling tiles that DS0000066920.V317510.R01.S.doc Version 5.2 Page 27 Green Lane (122) 5. YA37 8(1)(b) have been stained by water leakage, and redecorating the large lounge to include providing efficient ventilation. The registered provider shall appoint an individual to manage the care home where the registered provider is an organisation. The registered person shall give notice to The Commission of any theft or other event in the home. 03/12/06 6 YA41 37(f) 03/12/06 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 Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Green Lane (122) DS0000066920.V317510.R01.S.doc Version 5.2 Page 29 - 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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