Inspection on 28/04/08 for 193 St Andrews Road

This inspection was carried out on 28th April 2008.

CSCI found this care home to be providing an Good service.

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

193 St Andrews Road 04/09/06

193 St Andrews Road 01/02/06

193 St Andrews Road 04/10/05

193 St Andrews Road 18/03/05

193 St Andrews Road 03/12/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 St Andrews Road (193) Bridport Dorset DT6 3BW Lead Inspector Ms Marion Hurley Unannounced Inspection 28th April 2008 10:00 St Andrews Road (193) DS0000020420.V361481.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 St Andrews Road (193) DS0000020420.V361481.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. St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Andrews Road (193) Address Bridport Dorset DT6 3BW 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) 01308 425824 drh.193standrews@tiscali.co.uk www.drh-uk.com Dorset Residential Homes Mrs Cheryl Lisa Jarvis Care Home 8 Category(ies) of Learning disability (8) registration, with number of places St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th September 2006 Brief Description of the Service: 193 St Andrews Road provides twenty- four hour care for eight people of both genders with a learning disability and who may also have associated emotional and behavioural needs. The people who live at 193 each have their room and the communal accommodation is comfortable and includes a lounge, dining room and conservatory, plus kitchen, bathrooms, and laundry. The people who live at 193 are, in general, physically independent though the home does have a passenger lift to the first floor. There is a good size enclosed garden. Three of the residents have their own areas in which to garden and grow produce. Private car parking is available to the rear of the building and there is access to local transport in addition to the homes own vehicles. The home is located in Bridport within easy reach of the town centre. It is a large detached property that has been carefully extended and adapted to meet the needs of the residents. The home is managed by Dorset Residential Homes, a registered charitable trust that operates a number of care homes in Dorset. The fees are decided on an individual basis, dependent on the needs of the service user. St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use the service experience good outcomes. This inspection was undertaken as part of the statutory inspection process in accordance with the Care Standards Act, 2000. All key standards were assessed according to the Care Home for Adults (18-65) National Minimum Standards. Key inspections are aimed at making sure that the individual services are meeting the standards and that outcomes are promoting the best interests of the people living in the home. Pre inspection information was obtained from a variety of sources including an annual self-assessment. This assessment is aimed at looking at how services are performing and achieving outcomes for people. It is now a legal requirement for services to complete and return the Annual Quality Assurance Assessment (AQAA). The deputy manager had completed the AQAA identifying positive aspects of the service and areas for development. The site visit to the home was completed in one day. Several of the people at the home have limited ability to understand and fully communicate in words. Therefore many judgements in this report are from observation and reading residents’ records and documents. Some residents met during the inspection visit were able to help by giving a limited opinion about the care and services provided. No relatives or visitors were present during the course of the inspection. Three members of staff were spoken to as part of this inspection, documents were read, and medication inspected to form an opinion about the quality of the care provided to residents. A partial tour of the building was undertaken, all communal areas were seen, and a sample of bedrooms to make sure the environment is safe and homely. The manager was visiting another home at the time of this inspection though did volunteer to return to 193 however this was not considered necessary and the support from the two staff including the shift leader ensured all records and documentation were made available. The staff were very helpful and demonstrated a pro-active approach to ensuring that the people living at 193 were being supported to the best of their abilities and resources and the inspector would like to thank all those involved in the inspection for their support and assistance. St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Since the last inspection the home has re-registered with the Commission and now only provides accommodation and personal care and support. Previously the home provided nursing care however, the home now accesses all Community Health resources for the residents at 193. This process was well managed and involved considerable consultation with parents and relatives of people living at 193 and other significant stakeholders. Throughout the last year redecoration has continued to ensure the environment remains fresh,clean and homely. The rota for senior staff has changed to ensure consistency amongst the staff team and in the care provided. St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 7 The cleaning schedules have been revised to ensure simpler system A member of staff has been nominated for the responsibility of overseeing the management of infection control within the home. Equality and diversity workbooks for staff are annually issued and completed to ensure staff remain proactive in their work with the people living at 193. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 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 St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. The home ensures people and their representatives have enough information to make a choice about where they live and their needs are assessed to ensure the home can meet them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and Service User Guide is current and has been reproduced since the home successfully completed a variation to become registered as a Care Home without specific nursing responsibilities. The organisation, Dorset Residential Homes has an appropriate admissions policy and procedure and assessment criteria, which would be fully utilised by the staff at 193. Although no one has moved into the home since the last inspection the pre-admission process and assessment is user sensitive and flexible. It ensures that the service users are appropriately placed at the home and the staff can meet their needs. If the person is potentially suitable the staff undertake a detailed assessment of all areas of need. The assessment is then reviewed to ensure staff have the skills and abilities to meet the service users needs. Copies of assessments of St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 10 the person are requested and received from other significant agencies e.g. clinical psychology. Staff said it would be usual for the pre admission visits to be frequent and gradually increasing in length and time but always at the pace of the service user. A transition care plan would be developed to cover the person’s initial move and settling in period. The files of three residents were read and included a comprehensive range of information based on contact with other professionals and relatives. It is recommended that the service consider the development of the service user guide in a pictorial format to encourage potential service users to understand the information about the home and help them make informed choices. St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good. Care plans are written for each person and give staff clear guidance about how to support service users with their needs. The service users are encouraged to make decisions and participate in the service that they receive to make sure it meets their needs and expectations. Risk assessments are considered and balanced and take account of the service users’ needs for independence as well as the need to minimise the risk of harm to them. This judgement has been made using available evidence including a visit to this service St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 12 EVIDENCE: There is a well organised system in place for information and care planning. Each person has a file for their care plan, a separate record of their personal allowances, and one for Medication Administration Record Sheets (MAR). The care planning includes a Lifestyle Plan, preferred Daily Plan, and Behavioural Plan. The plans are accessible to staff and ensure they can get access to the information they need to help and support service users. The plans offer clear guidance to staff about how to meet the service users needs and staff said this helped them to provide consistent care to the service users, and other documents such as physical interventions records indicate that staff have a good understanding of individual care plans and follow these. Each service user has records documenting their personal allowance and the records clearly showed any transactions. All entries were double signed and night staff regularly audit the service users personal accounts. The service user personal allowances are kept in individual wallets, which are stored securely. The care plans have assessments of risk which balance service users’ rights and their need to be safe, examples seen covered areas such as challenging or destructive behaviour. Staff commented that they felt all risks are properly assessed, kept under review, and said they were not placed in difficult positions by having inadequate information. Despite the presentation of the records being rather “academic” they presented clear guidelines and staff confirmed they were aware of their contents. However, management should consider the use of language in the records for example “mobilising freely,” is a vague term and does not describe the person’s ability. “L has experienced a holiday away” does not inform the reader whether the holiday was fun, enjoyable nor does the phrase encapsulate the essence of the holiday or the activities. All the behavioural guidelines were specific and included details of the persons likes and dislikes/preferences and this information could be cross-referenced from the recording in the daily notes. Staff are trained in physical intervention techniques, however they were very clear this rarely involved any form of physical restraint. Interventions are used positively to step back from the person or to guide them to an area of the home where they would be safe. St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 13 Staff said they felt they worked well as a team and offered each other support to make sure they and the service user are safe and protected and are sufficiently trained to deal with most difficult situations. Each resident is linked into a group worker system and staff from this group help the resident to identify and express his or her needs and aspirations. From discussions with staff and observations residents are clearly encouraged to be involved in decision making. Each resident file had a participation chart that is used for monitoring residents’ communication skills. It is recommended all old documentation referring to nursing are reviewed. St Andrews Road (193) DS0000020420.V361481.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): 12,13,15,16 and 17. Quality in this outcome area is good. People who use the service live busy and fulfilled lives and enjoy a wide range of community and home based activities and leisure interests that are age appropriate and broaden their experiences. Residents are supported to maintain important relationships in their lives. Residents’ rights are respected and the daily routines of the home encourage individual choices and provide residents with the opportunities to be as independent as possible. Routines are flexible and residents can lead their lives in a way that meets their individual needs and preferences. The food is of a good quality and residents have a varied and interesting diet which promotes healthy eating. This judgement has been made using available evidence including a visit to this service. St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 15 EVIDENCE: All the residents attend formal day services either in Sherborne or Bridport. Attendance is mostly on a part time basis, which ensures residents have time at home with their key workers to enjoy one to one sessions. Residents have annual holidays and trips out. Residents get plenty of opportunities to use community resources locally and further afield. On the day of the inspection one person went shopping with support to Yeovil. Staff said that the correct staffing levels were always maintained during trips and they never felt inadequate staffing levels compromised their safety or that of the residents. Residents have personal televisions, videos, music centres, computers and there is a large television and video in the communal lounge . Family and friends of residents are welcomed into the home. The service operates an open house policy and there are no restrictions on visiting. Residents can see visitors in the privacy of their own rooms or in one of the communal areas and some people visit their family homes. Staff were observed knocking on bedroom, toilet and bathroom doors to ensure privacy for the residents. Some residents have a key to their own bedroom others based on personal risk assessments do not manage their own key. However all rooms have a lockable facility though staff can override this with a key from the outside but this does allow the resident a sense of privacy. Residents were seen taking part in a cookery session and appeared to be enjoying this. Residents are also involved in the “big weekly shop for the house.” Menus are well balanced and varied and whilst there was no written evidence of people’s input into the menu planning staff confirmed people were consulted. St Andrews Road (193) DS0000020420.V361481.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. Residents are assisted with personal care according to their preferences and staff are very aware of issues of privacy and dignity. Residents’ health care needs are fully assessed and provided for well. Medication storage, administration, recording, and disposal are well managed and residents receive their medication as prescribed by their GP. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans showed peoples’ likes/dislikes and preferences and staff confirmed that they ask residents how they would like to be helped and who they would like to support them with their personal care tasks. Staff were observed ensuring peoples’ privacy by closing toilet doors, and asking for entrance into bedrooms and knocking on the doors of peoples’ private space. St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 17 Health care plans and records were seen and these included weight charts where appropriate. Copies of correspondence indicated a positive level of multi disciplinary work and additional evidence of medical appointments were all seen on the files. Staff said that residents all have regular appointments with the dentist, optician, and chiropodist and that residents’ health was well catered for with specialist help being sought straight away if needed. Medication storage was checked to make sure it was secure. There is a locked cabinet, a medication fridge, and a separate locked storage for controlled drugs. Medication records were properly maintained and showed what medication residents took and when and included protocol’s for the use of medication prescribed to be taken “when necessary.” The controlled drugs are counted down and the tablets tally with the records which shows they are handled safely. All senior staff are assessed before they are allowed to give medication to make sure they understand their roles and responsibilities. It is understood all senior staff have completed medication administration training however it was quite difficult to verify this information from the training records. As previously commented staff need to be aware of the language used and should endeavour to use plain English for example “ appears to have the potential to experience sun burn during the summer months,” is a rather elaborate way of telling staff to be aware of the risks of sun burn. St Andrews Road (193) DS0000020420.V361481.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. The home protects people from all forms of abuse and has a robust complaints system. It has detailed guidelines to help people with behaviours that may cause themselves or others distress. Residents are protected from harm and abuse by staff that are aware of the issues and trained to understand their roles and responsibilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission has received no information about this service with regard to complaints or safeguarding adult issues since the last inspection. There is a robust complaints policy and to help residents know who to talk to if they are not happy a rota board is prominently displayed so people can see who is on duty, this includes the night staff. Incident sheets and other documentation provide descriptions of events, which have occurred since the last inspection e.g. Regulation 37 reports. There is an organisational (DRH) Adult Abuse Policy and the home had a copy of the multi-agency No Secrets Policy. St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 19 The home has clear guidelines with regard to helping those people who may have behaviours that distress themselves or others. The home will only use physical intervention as a last resort. All staff receive appropriate training in non-physical intervention and learning how to safely withdraw from a situation whilst ensuring the safety of all the residents. All administration of residents’ monies requires two signatures and samples looked at were found to be accurately recorded with receipts kept for all expenditure. St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is good. The home is safe, properly maintained and is made homely for the residents living there. It is clean and good hygiene practices are followed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial tour of the building was completed (including a sample of bedrooms) to make sure that the home was safe, well maintained, comfortable and homely. The building gets a considerable amount of wear and tear because of the needs of the residents, and it was evident throughout the building that the maintenance is good, and repair work is quickly undertaken to repair and improve facilities. St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 21 It offers comfortable and practical accommodation that is mostly well decorated and pleasantly furnished. There is ample space and seating in all the communal areas. Several areas of the home are due for redecoration this financial year. Since the last inspection the new accommodation has been completed and this has greatly enhanced the accommodation and now provides each person with his or her own bedroom. One of the new bedrooms has en suite facilities and the other two have their own toilets and washbasins. The home was relatively clean and tidy, considering the use it gets and good hygiene practices were observed in the laundry area. The kitchen was clean and well organised. The home has the necessary waste bins to prevent cross infection; they wash peoples’ laundry separately and have a robust cross infection policy. St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 22 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. The staffing levels are appropriate to the high level of needs that residents have and the staff team is cohesive and supportive meaning that residents are well cared for. The recruitment procedure is robust and offers good levels of protection to residents from staff that may potentially abuse them. Staff are well trained and properly supervised to check that they are competent to undertake their roles. This judgement has been made using available evidence including a visit to this service. St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 23 EVIDENCE: The home has a permanent team of staff, including two waking night staff. Each shift will have a minimum of three staff and this can rise to four for activities and special occasions. The use of agency or bank staff is kept to a minimum but when required the home attempts to ensure a consistency of care for the residents by using the same bank and agency staff wherever possible. Staff training records were viewed and individual records identified their mandatory training accomplishments and requirements. It was however more difficult from the records to ascertain other training competed e.g. the number of staff who currently are studying for National Vocational Qualifications and those successfully completed training courses. Fire training records were recorded in both the Fire Safety Folder and on individual records and it is important that all information is up to date and can be cross referenced for example details of staff fire safety training records in the Fire safety Folder were not as current as on the individual files and presented misleading information. Staff described the recruitment process stating they had to complete an application form, be interviewed, supply two written references and have a returned CRB check before they could start work, thereby making sure residents are protected. Staff are required as part of the process to visit the home and meet the residents. . St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 24 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 and 42 Quality in this outcome area is good. The registered manager is qualified, competent, and experienced to run the home and meet the organisations stated purpose, aims and objectives. The management approach of the home reflects the manager’s ability to run the service well and competently. There are various methods in place to informally and formally measure the quality of services and standards provided to those people both living and working at 193. The home meets health and safety requirements and keeps records to prove residents and s are safe at the home. This judgement has been made using available evidence including a visit to this service St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 25 EVIDENCE: The manager is registered and appropriately qualified. The manager is responsible for the running and management of 193 in addition to supporting other DRH services. These commitments do not detract from the overall management of 193. Health and safety records are regularly completed and checks are made at proper intervals. All safety certificates are in date. Risk assessments are comprehensive and records illustrated regular reviews. Health and safety servicing and testing records were inspected to make sure that residents are safe within the home and protected from harm. Suitably qualified people do all servicing and testing at the correct intervals. The health and welfare of residents and staff is well protected. St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 26 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 X St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA1 YA7 Good Practice Recommendations Different formats for the service user guide should be developed. It is recommended that staff consider the terminology and phrases used in some care plans and should endeavour to use everyday language. St Andrews Road (193) DS0000020420.V361481.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 St Andrews Road (193) DS0000020420.V361481.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. 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. 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