Inspection on 08/02/07 for 26, Egerton Road

This inspection was carried out on 8th February 2007.

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

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

Other inspections for this house

26, Egerton Road 26/01/06

26, Egerton Road 20/09/05

26, Egerton Road 02/02/05

26, Egerton Road 19/07/04

26, Egerton Road 18/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 26, Egerton Road Twickenham Middlesex TW2 7SP Lead Inspector Sandy Patrick Unannounced Inspection 8th February 2007 10:00 26, Egerton Road DS0000030462.V334223.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 26, Egerton Road DS0000030462.V334223.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. 26, Egerton Road DS0000030462.V334223.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 26, Egerton Road Address Twickenham Middlesex TW2 7SP 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) 020 8891 6308 02087449478 London Borough Of Richmond Upon Thames Kimberley Jane Poulter-Dell Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 26, Egerton Road DS0000030462.V334223.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2006 Brief Description of the Service: 26 Egerton Road is a residential care home providing short term accommodation for up to six adults with a learning disability. The service is managed by the London Borough of Richmond. Staffing levels reflect the needs of the service users who are staying there at any given time. Staffing is provided over twenty-four hours. Over forty service users stay at the service throughout the year. The average stay at the home is between one night and three weeks at a time. Some service users remain at the home for longer if there is a specific need, for example they are waiting for another longer term placement. The home is situated in a quiet residential road and is in keeping with the neighbouring houses. Whitton and Twickenham town centres are a short distance away. The area is well serviced by transport links and local amenities. The Registered Persons have produced a Statement of Purpose, which includes information on the aims and objectives of the service. 26, Egerton Road DS0000030462.V334223.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit on 8th February 2007 was unannounced. The Inspector met with some of the people who were staying at the home, staff on duty and the Manager. On 5th February the Inspector and a colleague attended a meeting for parents and carers of service users. They had the opportunity to ask what people felt about the service and if they had any areas of concern. The Inspector also sent questionnaires to service users, their relatives and staff asking them what they felt about Egerton Road. Nineteen service users, sixteen carers and relatives and four members of staff completed questionnaires. People found the staff kind and helpful and were happy with the service. Some people had specific concerns and these were discussed with the Manager. The names of the people completing questionnaires were not shared with the Manager. The Inspector also looked at some of the records, the environment and talked about things that had taken place at the home since the last inspection. Five people were staying at the home at the time of the inspection. Some of the things that people who use the service said were: ‘The food is great.’ ‘I enjoy the day trips and parties.’ ‘This is a nice place and the helpers are kind.’ ‘Nice food and we go food shopping, nice bedroom. It is very good.’ ‘I like seeing my friends at the home.’ ‘The staff make me feel happy they give me support.’ ‘There are nice rooms but I would like table lamps.’ ‘It is a lovely place and I always enjoy going there. The staff are excellent.’ Some of the things which relatives and carers said were: ‘The respite is a lifeline we could not do without. The staff are caring both to clients and carers and are always at the end of the phone. service.’ ‘Egerton Road and its staff are very good in every way, nothing needs to be changed.’ ‘The staff communicate very well and are supportive.’ 26, Egerton Road DS0000030462.V334223.R01.S.doc Version 5.2 Page 6 A wonderful ‘I have always found Egerton Road to be very well run and clean.’ ‘My son loves to stay at the home and I am confident he is in the best hands.’ ‘The staff are wonderful. We always feel our son is safe and happy there.’ What the service does well: What has improved since the last inspection? What they could do better: The Manager and staff are working with people who use the service to make things even better. They have thought of some ideas for this and want people to use the service to give them even more ideas. 26, Egerton Road DS0000030462.V334223.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. The summary of this inspection report can be made available in other formats on request. 26, Egerton Road DS0000030462.V334223.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 26, Egerton Road DS0000030462.V334223.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, 2 & 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is a good range of accessible information available for people wanting to use the service. The service meets the needs of the individual people who stay at the home. The staff work with other professionals to make sure they have a good understanding of each person’s needs. EVIDENCE: The staff have developed a range of information for prospective service users, care managers and carers. These include a Service User Guide, which uses easy words, pictures and photographs to help people to understand what it is like staying at the home, what they can expect from staff and what is expected of them. The guide includes photographs of all the staff. There is information on complaints which is supported by pictures and photographs of the people who should be contacted if someone is unhappy about the service. 26, Egerton Road DS0000030462.V334223.R01.S.doc Version 5.2 Page 10 These leaflets are given to people who are interested in using the service and all people staying at the home are given a copy. The guides are well laid out and information is clear and accessible. The service has room to accommodate up to six people at any one time. Some people have specific needs which mean that it is important that there are less than six people staying at the home when they are. The staff have a good understanding of this and try to arrange the service to meet individual needs. The London Borough of Richmond have appropriate assessment procedures and work with other services to develop a picture of each person’s needs. There is a suitable referral system to the home. The Manager has made links with care management and children and families teams at London Borough of Richmond to inform people about the service. She has also visited schools and colleges to meet with prospective service users and the staff from the services that they use. The Manager said that over the last year there has been more interest from young people leaving full time education about the respite service. New people from different ethnic backgrounds have also started to use the service. The Manager and staff assess each person’s needs individually and address any cultural or specialist needs within care plans. People who completed questionnaires for the CSCI said that they were able to visit Egerton Road and make a choice about whether they wanted to stay there. 26, Egerton Road DS0000030462.V334223.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, 8 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments give information on individual needs. People who use the service make choices about their lives and the way the service is run. Information is accessible and easy for service users to understand. EVIDENCE: Each service user has a care plan and risk assessments which cover their needs whilst staying at Egerton Road. These are reviewed regularly. Daily records are made whenever someone is staying at the home. Some of the relatives and carers who contacted the CSCI said that they would like to see person centred plans being developed that covered individual needs for all aspects of the person’s life. The staff at Egerton Road are keen to be 26, Egerton Road DS0000030462.V334223.R01.S.doc Version 5.2 Page 12 involved with this. planning. The staff have all attended training in person centred The respite service holds regular meetings for people who use the service. These meetings are used to inform people and to gain their views and opinions of changes and developments. The new Service User Guide and complaints procedure have been approved by the group and they have been able to contributed their ideas for changes. People attending the meetings also help plan activities and parties. The staff have developed a survey to ask people who stay at Egerton Road what they think of the meals that they have there. The staff said that they plan to develop further surveys and comment cards about other aspects of the service. These will be handed out for people to give feedback and make suggestions. The staff are currently looking at developing a regular newsletter for people using the service. Representatives from the service user group will help with this. The Manager said that she hopes to purchase a computer for the service users. The staff are developing a webpage which will give prospective and existing service users information. People who completed questionnaires for the CSCI said that they made decisions about their lives and made choices while they were staying at Egerton Road. 26, Egerton Road DS0000030462.V334223.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People are supported to learn new skills and try new things. There is a wide range of different leisure opportunities for everybody. Carers and relatives feel confident that the people staying at Egerton Road are in safe hands. The staff respect everyone and treat them well. The food at Egerton Road is well prepared, fresh and meets individual needs. 26, Egerton Road DS0000030462.V334223.R01.S.doc Version 5.2 Page 14 EVIDENCE: People who stay at Egerton Road are supported to learn and develop new skills. These include cooking, cleaning, using the community and travelling. The staff have started to put together photographs to show how some people have got on with learning new things. The Inspector saw a collection of photographs which showed someone preparing, cooking and then enjoying a meal. The respite service holds regular meetings, outings and clubs for all service users and not just the people staying at the home at any one time. People staying at the home are able to join these events and staff also organise outings and events for people in small groups. Earlier in the year Egerton Road celebrated the ten year anniversary of the service. There was a party where all the people using the service at the moment, past service users, families and staff were invited. The party was a success and people were able to write comments about their experiences in a special book. Photographs of the party and other special events were viewed by the Inspector. Special events around Halloween, Christmas and the New year were also organised. Regular outings include meals out, cinema, bowling and using other local leisure facilities. There have also been a number of trips further afield and special events, such as a murder mystery evening! Information about trips and special events is recorded and everyone has an opportunity to record their experiences. Events are well advertised and the people using the service help with planning events. Generally people staying at the home continue to access their normal day services. These include jobs, using local resource centres and colleges. When people do not have a specific day activity planned, then staff at the home support them to pursue individual interests. People staying at the home are involved in the day-to-day household activities. The Deputy Manager has started to meet regularly with managers and staff from the local resources centres. She said that this close working had benefited people using both services and helped all staff to have a better understanding of individual needs. People staying at the home are supported to stay in contact with their families and friends. There is a wide social network and lots of friendships amongst people who have used the service for many years. The staff try to organise for friends to stay together at the same time if they want to. Families and carers are invited to regular meetings and are welcomed in the home at any time. 26, Egerton Road DS0000030462.V334223.R01.S.doc Version 5.2 Page 15 The Inspector met with a group of carers and relatives at an organised meeting shortly before the inspection visit and also met with relatives who were dropping people off for their stay on the day of the visit. A number of relatives and carers also completed CSCI questionnaires. They overwhelming said that they feel well supported and informed by the staff at the home. They said that they were made welcome when they visited. The meetings are used to share information and also as a social network for relatives and carers to support each other. Some of the relatives said that they did not always feel well informed by other departments within the London Borough of Richmond and that they would like more information about day care, reviews and person centred plans. This information has been shared with CSCI departments who regularly meet with senior managers of the London Borough of Richmond. The Inspector saw examples of staff treating people with respect and allowing them to make choices. All the staff who spoke with the Inspector had a good understanding of individual rights. People staying at the home are able to choose their meals on a daily basis. The kitchen is well stocked with quality food and ingredients and the staff make sure they purchase food that people need or like for individual stays. People are supported to help prepare their food. Choices are recorded. The staff have an excellent understanding of nutrition and offer food that is wholesome and freshly prepared. The Manager said that some people who stay at the home have specialist diets because of health or cultural reasons. These are maintained and staff showed a good understanding of this. There are a range of snacks, fresh fruit and drinks available for people to have throughout the day and night if they like. 26, Egerton Road DS0000030462.V334223.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 & 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The staff work with other professionals to meet the personal care, health and medication needs of the people who use the service. EVIDENCE: Care plans include information on personal and health care needs. People staying at Egerton Road remain registered with their ordinary GP. Staff work closely with health care professionals to make sure they have information and support to meet individual needs. There is a suitable medication procedure which is regularly reviewed. The Manager has consulted with other professionals, including the CSCI Pharmacist, to make sure procedures are safe and in the best interest of the people who stay at the home. People who administer their own medication are supported to continue to do so whilst staying at Egerton Road. Medication is stored securely and accurate records of medication received, held at the home, administered and returned are kept. There are risk assessments for people who manage their own medication. 26, Egerton Road DS0000030462.V334223.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are procedures in place to safeguard the people who use the service. People who use the service know how to make a complaint and are supported by a range of accessible information. EVIDENCE: The staff have created a new complaints procedure which explains what people need to do if they are unhappy in easy words, pictures and photographs. The service user group has approved this. The information includes photographs of key people who listen to complaints and concerns. The staff have also developed new complaint forms which make it easier for someone to discuss what they are unhappy about and what they want to be done about it. The form includes easy words, pictures and a number of different options which are common areas of concern. There have not been any complaints about the service since the last inspection. The Manager spoke about how staff had supported one service user who had concerns about another person. There were records to show how this was dealt with. Everybody who completed a questionnaire for the CSCI said that they knew who to speak to if they were unhappy about anything. 26, Egerton Road DS0000030462.V334223.R01.S.doc Version 5.2 Page 18 The London Borough of Richmond have suitable procedures regarding protection of vulnerable adults and whistle blowing. The staff are familiar with these. All staff have had training in protection of vulnerable adults. The Manager has had additional advanced training. She said that this was very useful in gaining an understanding of the borough’s procedure and how to work with other parties to keep service users safe. The staff have helped develop systems to protect service users who go out alone and may be at risk. These include issuing all service users with a card giving details of Egerton Road. 26, Egerton Road DS0000030462.V334223.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 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The environment is well maintained and is designed to meet the different needs of the people who stay at the home. The home is kept clean. EVIDENCE: 26, Egerton Road DS0000030462.V334223.R01.S.doc Version 5.2 Page 20 The house is detached and has an attractive garden area. parking in two driveways. There is off road All bedrooms are for one person. One bedroom is small and does not contain a hand washbasin. Service users have appropriate information regarding this room prior to admission. Staff reported that this room meets the individual needs of some of the service users. All bedrooms are appropriately furnished and equipped. Service users are able to bring their own belongings to personalise rooms during their stay. Service users are able to make choices about the bedroom they wish to occupy, and the home try to accommodate this choice, providing their needs can be met in this room. All bedrooms seen by the Inspector were attractively decorated and comfortable. The building is equipped with grab rails throughout. Two bedrooms have been especially adapted to accommodate service users who are physically dependent. Both rooms have ceiling track hoists leading to a bathroom. All bedrooms are equipped with a call bell system. The kitchen is equipped with adjustable surfaces and there are low-level light switches throughout. Service users have been involved in purchasing new equipment and furniture for the home. Bedrooms and communal areas are attractively decorated. Two new beds have been purchased since the last inspection. The home now has three specialist beds which can offer support to people with physical needs. The home was clean and well maintained at the time of the inspection. 26, Egerton Road DS0000030462.V334223.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): 31, 32, 33, 34, 35 & 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The staff have been appropriately recruited, trained and are supported in their roles. EVIDENCE: There have been no staff changes since the last inspection and the majority of staff have worked at the service for several years. The staff know the service users well and the people using the service and their families feel confident that they are well looked after. People completing questionnaires for the CSCI said that the staff treated them well and respected them. The staff have a range of skills and interests that they use to help develop the service. They regularly attend training and have undertaken specialist training around their roles. All staff have achieved or are working towards NVQ qualifications. 26, Egerton Road DS0000030462.V334223.R01.S.doc Version 5.2 Page 22 The staff team meet regularly and have excellent systems of communication with each other. They work closely with other departments and service providers to have a holistic view of the people who stay at Egerton Road. The London Borough of Richmond has sound recruitment procedures and appropriate checks are made on staff before they are employed. Staff records are kept at the home and show clear evidence of thorough checks, interviews and a full induction into the home. Four members of staff completed questionnaires for the CSCI. They all said that they were well supported and trained and that they had regular and individual supervision team meetings. They all felt that they could contribute to the running of the home. 26, Egerton Road DS0000030462.V334223.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, 38, 39 & 42 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The service is well managed and the Manager works towards continuous development. People using and working for the service are able to contribute. There are excellent systems to monitor quality. EVIDENCE: The Manager has worked at the home for many years and is familiar with the needs of the service. She has an excellent knowledge of individual service users and staff and has shown a commitment to continuous improvement of the service. She is currently undertaking her Registered Managers Award. 26, Egerton Road DS0000030462.V334223.R01.S.doc Version 5.2 Page 24 The Deputy Manager has also worked at the home for many years and has a very good understanding of the service. She is qualified to NVQ Level4. Staff who spoke to the Inspector and those completing questionnaires all said that they felt well supported and were able to contribute their ideas. They praised the Manager and said that they worked well as a team. Egerton Road has good quality monitoring systems. The staff regularly consult with the service user group and involve them in any changes and development of new systems and paperwork. New comment cards are being developed for people staying at the home to comment on a particular area of the service. The staff also send out annual questionnaires to all service users asking them about a range of different things. These include making choices, being listened to, learning new skills, being supported to be independent, feeling safe, being healthy and being respected. The questions are based on the local authority quality standards, which have been developed using information from service users across the borough. Recently questionnaires were sent to everybody using the service. 53 of people responded. The Manager has looked at the answers people have given and used their comments to look at how the service can be developed. The questionnaires have also helped the staff to see if people need particular support in other areas of their lives. The London Borough of Richmond quality standards are discussed at staff meetings and the staff have been asked to think about and record how they think these are implemented at the home and what more they could do. The Manager is involved in peer monitoring of other London Borough of Richmond homes. This will support a wider understanding of quality monitoring and may help Manager to have new ideas from different homes. The staff team all contribute to developing a team plan which looks at things they feel need to be done for the future. There are suitable systems for monitoring health and safety. appropriately recorded. Checks are The Manager has developed a pictorial guide to good food hygiene and safety in the kitchen. This is displayed for staff and people staying at the home. 26, Egerton Road DS0000030462.V334223.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 4 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 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 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 4 4 X X X 3 26, Egerton Road DS0000030462.V334223.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 26, Egerton Road DS0000030462.V334223.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 26, Egerton Road DS0000030462.V334223.R01.S.doc Version 5.2 Page 28 - 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!