Inspection on 05/09/06 for 25 Horsegate

This inspection was carried out on 5th September 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

25 Horsegate 25/01/06

25 Horsegate 10/08/05

25 Horsegate 08/02/05

25 Horsegate 05/08/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 25 Horsegate Deeping St James Peterborough PE6 8EW Lead Inspector Sue Hayward Key Unannounced Inspection 5th September 2006 11:45 25 Horsegate DS0000002655.V310384.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 25 Horsegate DS0000002655.V310384.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. 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 25 Horsegate Address Deeping St James Peterborough PE6 8EW 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) 01778 347037 albert.pearce@sense.org.uk www.sense.org.uk Sense, The National Deafblind and Rubella Association Mr Albert Pearce Care Home 6 Category(ies) of Learning disability (0), Sensory impairment (6) registration, with number of places 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 6 sensory impairment/learning disability Date of last inspection 25th January 2006 Brief Description of the Service: 25 Horsegate is a modern house, built around 7 years ago. It is situated in the village of Deeping St James, approximately one mile from the centre of Market Deeping. There are a range of shops and pubs nearby, and the centres of Peterborough, Stamford and Bourne are within a short driving distance. The home is of a domestic appearance, and situated in a residential area. It is registered to provide accommodation for 6 people with a sensory impairment and/or learning disabilities. The aim of the home is to provide a safe and supportive environment, based on best care values. The home is part of a group of homes managed by SENSE East. The manger was present for the majority of the visit. Information provided at the time of the visit indicated that the current range of fees is from £1293.13 - £1726.34 per week. There are no additional charges. 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was undertaken by one inspector and formed part of a “key” inspection. A “key” inspection is the checking of those standards considered to be “key” in terms of the health, safety and welfare of service users. It also included checking whether issues raised at the previous inspection had been addressed. It started at 11:45 and lasted 6 hours. Information already held on file was used to plan the visit and produce this report. This included, records of any significant incidents that had been notified to the CSCI since the last inspection and any correspondence received. The manager said he had not received “Have your say questionnaires” to give to service users or their relatives nor a form to complete providing further information about aspects of the service although this had been sent out prior to the inspection. The main method used at the site visit was tracking the care and support received of a sample of two service users with a range of needs via their records, discussion with three staff members on duty and the manager. Bedrooms of those service users being case tracked were seen, as were the lounge, kitchen, dining room, bathrooms and toilets. As service users have very individual communication needs they were not involved directly. One was spoken to via a staff members support with communication and interpretation. Observation of staff working with service users was another method used to assess the manner in which care is provided. General feedback about the outcomes of the visit was given to the manager at the end of the visit. What the service does well: As homely environment as possible is provided for service users, which takes into account individual needs. Service users are supported and have opportunities to be as independent as possible, both within the home and the community by the range of domestic, recreational and leisure activities available for them to participate in should they be able and wish to. Staffing levels are sufficiently flexible to provide the support that service users need. Staff have a good knowledge of the needs of service users and there are ongoing training opportunities to ensure their knowledge and skills are updated to provide appropriate care for service users. Staff are able to communicate effectively in different ways according to the needs of service users. It was noted that on occasions whilst staff were communicating between themselves in front of service users sign language as well as the spoken word was used helping to ensure service users were included. 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 6 Record keeping systems in place are detailed and well maintained and there are a range of policies and procedures to ensure the health and welfare of service users. Service users community involvement is promoted through the use of local services and facilities where possible. There are good systems in place by the organisation to monitor the quality of the service, which includes the involvement of service users if able. A service user spoken to said he liked the staff and his room. What has improved since the last inspection? What they could do better: There has been some progress to ensure that service user care plans and risk assessments have been reviewed and updated but some still need to be done. This will ensure that any new employees have the most up to date information available to them. The manager agreed that the outstanding ones would be completed within the month. Medication key holding arrangements need changing to ensure that there is a safer system in operation. The manager confirmed at the time of the site visit how this would be addressed. 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 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. 25 Horsegate DS0000002655.V310384.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 25 Horsegate DS0000002655.V310384.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There is a satisfactory assessment process in operation, which ensures that service users needs are fully identified prior to their admission and staff have sufficient information available for them to provide appropriate care. EVIDENCE: Discussion with staff and the manager confirmed there have been no new admissions and most of the service users have been at the home for a number of years. The statement of purpose, which gives information about the service has been reviewed this year and is available in the hall. It is in symbol form to aid communication although as service users have very individual communication needs the manager said it was unlikely that they would be able to fully understand it in this form. However, the admission process is a planned system incorporating visits to and from the prospective service users gradually over a period of time. This includes overnight and weekend stays to assist with familiarisation. Relatives and other professionals are also welcome to visit and are given information about the home. The organisation has a team of staff who deal with any applications for admissions. The manager said that he would have some involvement in the assessment process and compatibility 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 10 with other service users was an important factor to be considered. Both service users records checked on this occasion contained a detailed personal support plans and individual risk assessments indicating that the needs of service users were properly assessed and planned for. 25 Horsegate DS0000002655.V310384.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Detailed care plans ensure there is sufficient information available for staff to meet the needs of service users. Service users are supported to make choices and decisions about their lives. EVIDENCE: Both service users files checked on this occasion contained detailed care plans. Whilst one had recently been reviewed the other was in the process of being so. This issue has been raised on previous occasions. The manager confirmed that the review of care plans and risk assessments would be completed in a month’s time. As this matter is in the process of being addressed, the requirement made for compliance in respect of this issue has been removed. The manager said current service users did not attend their reviews in view of their needs. Reviews are held six monthly. Relatives, staff from the home, funding authorities and other relevant professionals are invited to attend. The manager said that the inclusion of a service user for part of his review is being 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 12 assessed in order that this process can be done in a way that is meaningful and enables the service user to contribute to it. As well as care plans both files checked contained behaviour guidelines, risk assessments and health care assessments. There are good daily reports kept, which travel with service users to the resource centre they attend. This ensures continuity of care and good communication. Staff used a variety of methods to communicate with service users such as sign language, pictorially and using the spoken word. All staff spoken to had a good knowledge of the needs of service users and how to meet them. Service users were noted to be able to come and go around the house as they wished with staff providing support as needed. Staff gave examples of ways in which they promote service users to make choices and decisions for example, the activities they wish to participate in. Records checked indicated examples of service users having choices such as the time they arose and went to bed. Risk assessments were seen in place on both files checked and information indicated that matters such catering skills had been risk assessed to enable service users to be as independent as possible. 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 13 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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There are good occupational, recreational and leisure opportunities available for service users to participate in both within the home and community. These are based on service users individual preferences and promote independence and contact to and from relatives and friends. A well balanced diet, which incorporates service users individual preferences and specific dietary needs is provided. EVIDENCE: Information obtained through staff discussion, records checked and observations made indicated that service users are able to participate in a wide range of activities and leisure interests both within the home and community. For example, tobogganing, horse riding, craft work, swimming, attending the theatre, local pubs and shops and attending a resource centre operated by the organisation in Bourne are all options available. A local 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 14 Church holds sensory events, which service users can attend if they wish. All but one service user has had at least one holiday this year. These have been varied to meet individual needs and interests. The one person who chose not to have a holiday away had days out instead. Where able, staff said service users attend local services such as doctors, dentists and opticians. Staff confirmed that service users have the use of a mini-bus for trips out. During discussion with staff and observations made it was evident that service users are assisted to have contact with their relatives, for example staff accompany some to have holidays with their relatives and visitors are welcomed at the home. Care plans checked gave information about particular routines and preferences, which were reflected in staff’s knowledge of service users. Service users are promoted to be as independent as possible for example in participating with making their own packed lunches and involvement in the cleaning of their bedrooms with staff support. Observations made indicated that service users privacy is respected, for example one has a key to his bedroom. Staff gave examples of how they maintain privacy when dealing with personal hygiene matters such as incontinency. Catering arrangements are domestic in nature. Records of meals are kept although these varied on occasions as to the detail they contained and did not always give a clear picture of all the options available such as at breakfast time, which staff said were available. The manager agreed that this matter would be addressed. The individual records of service users checked demonstrated that nutritional needs are monitored as are specific requirements such as food being cut up small for a service user who has difficulty with swallowing. There is generally a set main meal with individual preferences and needs being catered for. On the day of the visit the main meal consisted of a vegetarian or meat option and a fresh fruit salad. A service user communicated through a staff member that he liked the meals provided. 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 15 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users receive care that promotes their health, welfare and independence and respects their individuality. There are satisfactory medication administration procedures in place although current key holding arrangements pose a risk as they are not sufficiently secure. EVIDENCE: Discussion with staff and observations made during the visit indicated that staff communicate well with service users, promote their independence and respect their privacy. For example it was noticed that a resident who received a telephone call was enabled to take it in private. However, staff said that all service users require a very high level of support and supervision in all aspects of their lives. Health action plans were seen for both service users being case tracked. These demonstrated service users health needs and the health professionals involved. Services users are supported to use local services where possible. This assists with communication and provides reassurance and consistency for service users. It was observed on the day of the visit that the manager 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 16 returned from accompanying a service user to attend a dental appointment. The organisation also employs a behaviour therapist and both files checked contained individual behaviour guidelines for staff to follow. Service users weight is monitored on a monthly basis, another example of the way in which health is monitored. The CSCI has been appropriately notified of accidents and incidents that have occurred which affect the welfare of service users and of the action taken to address them. At the last inspection a matter was raised in relation to consent issues about the administration of medication to some residents in food. This has been satisfactorily addressed and advice has been obtained in writing from the local pharmacist about the matter. Information also indicated there has been consultation with general practitioners about this matter. Staff said that they all receive training and have to be deemed competent by the management team prior to being able to administer medication (records are kept, which demonstrate this). Staff said service users are told on each occasion where medication is disguised in food. There are good systems for stocktaking and the disposal of medication. The home uses a Nomad system, where tablets are pre-packed by the pharmacist. An issue was raised about the security of the keys to the medication cabinet during the inspection. The manager agreed and discussed how this would be addressed to ensure a safer system was put in place. The local pharmacist visits the home periodically to advise and check systems in place. The last visit occurred on 10/05/06 and no major issues were raised. 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 17 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There are effective procedures in place for dealing with complaints and adult protection issues, ensuring that residents are safe. EVIDENCE: The organisation has comprehensive procedures in place relating to adult protection and raising concerns and complaints. A staff member demonstrated a good knowledge of the procedures, the forms that abuse can take and who to contact should a complaint or allegation be made. Staff receive training in relation to adult protection. It is also discussed as a standing item at the monthly staff meetings held. The complaints procedure is available in symbol form to assist with communication however staff said they also rely on their observations of service users as to their satisfaction with the service. A service user who spoke to the inspector via a staff member aiding with communication said he liked living at the home. There are satisfactory arrangements for the safe keeping of service users money and valuables and records checked balanced with the money held in safe keeping on behalf of a service user. The organisation also have a financial auditing system in place. Neither the home nor the CSCI have received any complaints or concerns about the service since the last inspection. 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 18 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A comfortable and homely environment is provided for service users, which is generally well maintained and clean. EVIDENCE: The home is a domestic type property. Two bedrooms were seen as part of the case tracking process. Both were decorated and furnished according to the needs of the individual service user. There was evidence of service users having their own personal effects around them for example one had bought his own easy chair which was in the lounge. There are still some maintenance issues outstanding but records and discussion with the manager indicated that these have been reported for action. The hall and stair carpet is showing signs of wear and tear and has been highlighted for replacement and a panel of a cupboard in the dining room needs repair. Shutters have been ordered for a service user who cannot tolerate curtains in his room. A service user communicated via a staff member that he liked his room. Bedrooms and bathrooms have flashing light systems. This helps to protect 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 19 service users privacy and dignity by alerting them to staff or visitors. There was discussion with a member of the management team about the entrance to the front door, which has a high threshold, as there are service users who have restricted mobility. It was confirmed that a ramp had been requested. Stocks of gloves, aprons and alcohol hand washes were available. A staff member confirmed that these are used when assisting residents with personal hygiene needs. Those communal areas of the home seen which included the lounge, dining room and kitchen were generally clean and tidy. A downstairs toilet did not have a bin provided for paper hand towels to be disposed of, the kitchen bin being used for this purpose. The manager should check with the Environmental Health Department that this practice is acceptable in terms of infection control. There is a separate laundry, which includes an industrial washing machine. There is an on-going programme of redecoration and the manager confirmed that since the last inspection the lounge and dining room has been redecorated and new lights fitted. 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 20 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 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staff are employed in sufficient numbers to meet the needs of service users and are well trained and supported the management team. There is a thorough recruitment procedure in operation. This ensures as far as possible that service users are protected. EVIDENCE: The organisation has a satisfactory training programme in place, which all new employees attend over a six-week period. In addition new staff work three observational shifts prior to being included on the duty rota. A new staff member was undertaking her first observatory shift on the day of the visit and it was noticed that this included instruction about fore safety and time to read other policies and procedures. Staff training is updated periodically for example crisis prevention intervention training, which is updated on an annual basis. Records of training are computerised and demonstrate the future training planned, for example moving and handling is due on 21st and 26th September. A staff member confirmed that he had participated in a range of training since his employment. A service user seen communicated that he liked the staff and 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 21 staff were noticed to respond promptly to help service users as needed. Rotas checked and discussion with staff indicated that there are generally a minimum of three staff on duty in the mornings, six in the evening and one wakeful and one sleeping in and on-call at night. There is some flexibility with staffing arrangements to ensure that service users who need additional staff support when out in the community receive it. There is currently one vacant post. Existing staff said they work additional hours to cover vacancies. This helps to ensure service users receive continuity of care. The manager said only one new person has been employed since last inspection and records checked of the recruitment process demonstrated a thorough procedure is operated. This had included obtaining two references and a satisfactory criminals record bureau check and protection of vulnerable adults register check prior to employment. 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 22 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is well managed. There are satisfactory systems in place to help ensure the safety and welfare of service users. There are good quality monitoring systems enabling service users if able relatives and staff to contribute to the development of the service. EVIDENCE: The manager has been at Horsegate for five years and has a registered managers award. Staff spoke positively about the management arrangements indicating that they felt well supported as either the manager or deputy are always contactable. A staff member confirmed that he has regular appraisal/supervision meetings and that staff meetings are held on a monthly basis. The manager generally works in an additional capacity to the staff rota however does some shifts to cover staff shortfalls. 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 23 The organisation has an internal quality audit system in place, which includes obtaining the views of service user where possible, relatives, staff and funding authorities via questionnaires. The last audit was carried out in January 2005. The manager confirmed that he is currently in the process of another audit. Service users have six monthly reviews and records indicated relatives and other professionals attend these. Discussion with the manager indicated that there are opportunities for any quality assurance matters to be raised during individual reviews. There are also regular health and safey audits and the CSCI has been receiving monthly reports of visits carried out by an area manager who comments on the quality of the service. Organisational policies and procedures are in place relating to health and safety issues and staff said they could refer to these as needed. The sample of records checked on this occasion included the fire risk assessments of the building and records of checks of the fire alram system and emergency lighting. These were up to date indicating that fire safety is promoted. 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 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 X 3 3 X 3 X X 3 X 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 25 NONE Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 25 Horsegate DS0000002655.V310384.R01.S.doc Version 5.2 Page 27 - 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!