Inspection on 25/06/07 for 3-4 Glebe Lane

This inspection was carried out on 25th June 2007.

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

3-4 Glebe Lane 15/03/06

3-4 Glebe Lane 09/08/05

3-4 Glebe Lane 15/03/05

3-4 Glebe Lane 12/06/04

3-4 Glebe Lane 26/02/04

Similar services:

Ruskin Lodge

Clover House

Dystlegh Grange

The Good Companions

Springfield Cottage

Cuerden Grange Rest Home

Parkside

Park Lodge

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

CARE HOME ADULTS 18-65 3/4 Glebe Lane Distington Workington Cumbria CA14 5SQ Lead Inspector Liz Kelley Unannounced Inspection 25th June 2007 10.00 3/4 Glebe Lane DS0000022557.V329081.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 3/4 Glebe Lane DS0000022557.V329081.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. 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3/4 Glebe Lane Address Distington Workington Cumbria CA14 5SQ 01946 831629 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) West House Mrs Fiona Elizabeth Dixon Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 8 service users to include: up to 8 service users in the category of Physical disabilities (PD) up to 8 service users in the category of Learning disabilities (LD) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 15th March 2006 Date of last inspection Brief Description of the Service: West House is the Registered Provider for 3 & 4 Glebe Lane which are two adjacent properties situated in a residential area close to the centre of the village of Distington on the West Coast of Cumbria. The properties provide accommodation and care for eight people who have a learning disability, some of whom may also have a physical disability. Number 3 Glebe Lane is a purpose built bungalow that has been built next door to the house, which is number 4 Glebe Lane. Each building has its own garden area and car parking is available to the front of the house and to the side and rear of the bungalow. Both properties look similar to the neighbouring houses in Glebe Lane. The home operates as two separate units. The house provides communal living space for service users together with an office / sleep - in room on the ground floor with private bedrooms and a bathroom on the first floor. The bungalow has level access into the hallway that is designed to assist service users who use wheelchairs to enter the building. All the communal rooms and private bedrooms are equipped to meet the needs of the service users. The current scale for charging is £746.75 per week. A Handbook is available for prospective residents, and the latest Commission for Social Care Inspection report is made available on request. 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an inspection where all the key areas of the National Minimum Standards were checked. Residents, and their families, and members of staff had given their opinions regarding the service and care to the inspector. These comments, and the observations made by the inspector, have informed the judgements made in this report. The inspector also: • Received questionnaires from professionals and other people working with the home • Interviewed the supervisor and staff • Visited the home, which included examining files and paperwork • Received a self-assessment report/questionnaire from the manager. On the day of this visit five people where at home and the house had a lively and friendly atmosphere with people busy making cups of tea, snacks and chatting with staff in the lounge. One person was busy in conversation about a family party she had been to the night before, and another was looking through recent holiday photographs. The overall picture gained by the Inspector was that people living at the home are very happy with being offered an individually tailored service that promotes choice and a good quality of life. What the service does well: What has improved since the last inspection? The manager and staff team have recently reviewed the paperwork and checking systems for the home that monitor both quality of care and the 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 6 building. This resulted in a much more effective system that targeted staff time and effort and allowed for more time to be freed up to spend in supporting people in the home. This demonstrates how the manager and staff are proactive in wanting to develop and improve the service. 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. 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 7 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 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 8 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): 2,3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s individual needs and preferences are assessed to ensure a suitable service can be provided. EVIDENCE: The home introduces new residents successfully by its careful selection and introductory procedures, which include thorough assessments and trial periods. Assessments completed as part of the admission process have been kept under review ensuring individual needs are monitored and care plans updated to meet changing needs. Because the majority of referrals to the home are from a Social worker all the residents have a Social work assessment on file. There was also evidence of specialist assessments being completed by other health professionals in addition to the home completing their own needs assessment, which are all used to compile the comprehensive care plans. In particular the home have some excellent communication assessments, which are valuable for ensuring the staff understand residents needs and preferences and communicate with them in a consistent manner. These assessments formed the basis of the individual’s plan of care and included any potential restrictions on choice, which were agreed by the resident. 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 9 One person had lived at the home for a few months and described how she had a series of visits, and was very happy when the time came to move. She said of her life now “I’m never in, I’m always out. You couldn’t ask for better. It’s a great place to live”. Clear information was also available to ensure that residents and relatives can make informed choices. The homes Statement of Purpose and Service Users Guide contain relevant details to assist residents, relatives and professionals in making an informed choice on the appropriateness of the home in meeting their needs. The latest Statement of Purpose includes pictures of all staff, photographs of the house and symbols which make the document easier to understand. All the residents had an up-to-date contract of terms and conditions signed and agreed by them or their representative and held on their personal file. This is good practice in ensuring people are fully informed of their rights and obligations. 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care plans are informative and reflect individual needs and choices, providing valuable information to staff to help them to give people personalised support and a good quality of life. EVIDENCE: People have care plans that are active documents and demonstrate the home’s careful monitoring of changing needs in order to support maximum independence. Care plans are in a style termed “Person Centred Plans” and staff use a variety of skills and ways to engage residents in planning their care and setting goals. Residents are involved through picture work, symbols, charts, and graphs and are encouraged to take ownership of their plans. The input from the resident is clearly evident and this is helped by plans being written in the first person and by the use of personal photographs. As one relative put it “They take the time to find out what makes each individual tick”. 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 11 Individual’s plans are regularly up-dated and revised when goals had been attained. Having two keyworkers nominated to each individual to take joint responsibility for care planning helps this. This leads to care plans that are dynamic and evolving documents that encourage significant personal development for residents. The home and the organisation are keen to involve residents in consultations and planning and a number of strategies were used to promote user involvement, for example through life skills groups and training, forums, and advocacy groups. Through the one to one support and consultation by key workers, the development of individual care plans and regular house meetings, people are able to contribute to all aspects of home life and raise any issues that are important to them. People enjoy a lot of autonomy making individual choices on a daily basis. This could be for example, what time to get up or go to bed or how they will spend their day. Assessments and care plans are cross-referenced to risk assessments to ensure people are safe. The assessments and care plans record information relating to personal care needs, health care, communication, medication, promoting independence and cultural needs. The areas assessed are wide ranging ensuring people are kept safe, while enjoying a fulfilling lifestyle of their choice. This ensures a personalised service is provided that responds to the diverse needs of people living in the home. The senior staff recently took the decision that care records are only completed when there is an important or significant event such as healthcare appointments and contact with other services and agencies. They also record issues which may lead to a care plan change. This is a much more targeted way of working and captures only meaningful events and leads to good quality records that mean something for the people living in the home. They also revised staff handover sessions, which now include an element of auditing, for example checking medication. Staff are then kept up to date with changes as they occur therefore ensuring a continuity of care is maintained. This demonstrates how the manager and staff are proactive in wanting to develop and improve the service. Personal and confidential information is securely stored at all times with staff having a good understanding for the need to maintain confidentiality both within and outside the home. 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home are able to pursue their chosen lifestyle and have their rights and choices respected by the staff team. EVIDENCE: The use of person centred plans ensures that each individual has a tailor made plan which includes details of their background, family, past interests and has very good detail on a persons likes, dislikes and their future aspirations. For one residents this has had a positive outcome of staff getting to know of a favourite family holiday destination, and they are now helping to organise a trip there. Another resident attends a local college to follow one of their interests in cookery. As one relative commented “I think the home helps the residents to live a life, they get out and about in the community.” 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 13 Not all residents attend day services every day, and the staff look for ways to involve them in the home mainly through one to one contact, conversation and carrying out daily tasks, such as frequent trips out to undertake everyday activities, such as shopping, banking etc. On the day of this visit five people where at home and the house had a lively and friendly atmosphere with people busy making cups of tea, snacks and chatting with staff in the lounge. One person was busy in conversation about a family party she had been to the night before, and another was looking through recent holiday photographs. People are supported to maintain and develop relationships, with relatives and friends. Some people are supported to visit their families. The home supports this with sensitivity and respect of each family’s circumstances. Relatives who returned comment cards as part of this inspection all commented positively on the support their relative receives from the staff team. Several of the more active residents have friendships with people from outside of the home who they have met at day services, college and social events. This extends to visiting each other in their own homes. The person-centred plans show how staff support people to maintain important relationships. Relatives commented “I always get information from the home before decisions are made” and “The staff regularly contact us or help my relative to phone to discuss matters or just for a general chat.” The meal arrangements are very flexible and staff are able to respond to individual requests. Menus and records sampled demonstrate that meals are of a good quality, and provide good nutritional value. The weekly menu is planned with residents and shopping is carried out with residents who take turns. Individual shopping is also encouraged to develop independence and daily living skills. Residents also enjoy a variety of take away meals and meals out. 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each individual’s health and medication is carefully monitored ensuring that they have access to services that help to maintain good health. EVIDENCE: Based on my discussions with people living in the home, observations of the staff, and also from the written records, people receive appropriate support to access the health services they require. Staff have a good understanding of residents healthcare needs. The staff team work positively with local health care professionals to offer a responsive and supportive approach in assisting people to maintain good health. Records on healthcare needs are well maintained and kept up-to-date, these are linked to care plans to alert staff on any changes, and include monitoring sheets for specific issues. The home has sensitively handled the ageing process and offers good support to minimise any impact on independence. The staff team are managing complex healthcare issues, as demonstrated on the day of inspection when a resident was being carefully monitored across a 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 15 period of illness. The protocols in place, that had been developed in conjunction with this persons’ GP, were examined and staff were observed to follow these to ensure that the person was safe and well cared for at all times. The senior was in regular contact with the GP across the day to seek advice and a visit was arranged for later in the day, and a member of staff remained with this person. Residents are registered with a GP of their choice and have access to other members of the Primary Health Care team. Other checks such as opticians and dental checks are also recorded on Healthcare files. Any personal care is delivered in residents own bedrooms and staff are aware of issues of dignity and privacy. For example this was well written up in the instructions for staff in using a hoist and how to best retain peoples dignity. Interactions were observed between staff and residents and this was carried out in a sensitive and respectful manner. 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures support and encourage good practice and safeguard people from abuse. EVIDENCE: Staff are trained to respond appropriately to physical and verbal aggression and fully understand the appropriate use of physical intervention. The style of intervention used focuses on diversion tactics rather than physical restraints, these are not used. Staff are encouraged to look for triggers and distraction measures and only when these fail is medication used to calm people down. This PRN medication has been agreed and reviewed by the residents Medical Consultant. The home follows a model of positive interaction to challenging behaviours and carefully monitor incidents to ensure they are using the right techniques with individuals. All records of these are sent into the Commission for Social Care Inspection. The ethos of the home is to promote positive handling of behaviours through greater awareness of behaviours and triggers. This has been helped by good relationships and advice from specialist social and health care professionals. The service has a complaints procedure that is up to date, clearly written, and is easy to understand. It can be made available on request in a number of formats (including other languages, large print, etc) to enable anyone associated with the service to complain or make suggestions for improvement. 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 17 The policies and procedures regarding protection of individuals are of a high quality and are regularly reviewed and updated. The service is clear when incidents need external input and who to refer incidents to. Training of staff in the area of protection is regularly arranged by the organisation. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding when incidents should be reported. 3/4 Glebe Lane DS0000022557.V329081.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, homely and comfortable environment that match their lifestyle needs. EVIDENCE: The Home is in the heart of a well-served community being situated in Distington on a newly developed housing estate and is similar to the surrounding properties. The furnishings and decoration are of a good standard and homely in style. The gardens have been made attractive through the efforts of staff to make up hanging baskets and plant up flower beds. Resident’s individuals bedrooms are of a good size and individualised to each persons tastes and interests. The home has good facilities for assisting people with limited mobility, such as an assisted bath, walk-in shower and electric beds. The Home meets the requirements of the Fire and Environmental Health services and has a maintenance and renewal programme to ensure that residents live in a safe and well maintain home. 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff recruitment, training and supervision practices are well developed which ensures that residents’ well-being is promoted, by staff who have the qualities, aptitudes and skills to support people. EVIDENCE: Glebe Lane has a core group of staff with a good mix of skills, experience, age, and gender, which reflects the profile of the residents. There has been less movement of staff in the last year and a relative comment card said “Staff come and go, but any changes in personnel which may have happened make no difference to the quality of care”. A new member of staff interviewed described their experience of the home “ Very supportive staff team, great atmosphere, and we all pull together”. All staff are clear regarding their role and what is expected of them. Relative comment cards stated that staff know what they are meant to do, and that they are able to meet their needs. 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 20 This leads to good levels of confidence and satisfaction from residents, relatives and professionals with the care that is delivered. “I feel the care home is exceptionally good at being home from home” said one relative, and another “My relative has become a new person since moving to the home. She has real quality of life, this is all due to the staff teams continuous quality of care” The Home follows the recruitment procedures of West House. Staff files are held in the home, and contained all the relevant documentation, being clearly sectioned and well-organised. The selection procedure includes obtaining two written references, a formal interview and an informal interview involving residents, wherever possible, and applications are subject to equal opportunities monitoring. All staff have CRB disclosure checks and a check list ensures that all safeguards are put in place prior to an appointment. Upon appointment staff were issued with a handbook, which includes job descriptions and terms and conditions. Appointments are subject to a sixmonth probationary period. West House has a code of conduct and all members of staff have a statement of terms and conditions. A member of staff who was interviewed confirmed these practices. These are all good practices to ensure that residents are supported by a carefully selected and vetted staff team. The home has a framework for supervisions and appraisals, and these have been carried out to good standards; staff reported that these are helpful and they feel well supported by the supervisor, manager and the organisation. Staff training continues to have a high profile in the home and staff are keen to gain new knowledge and skills that will assist them in supporting residents. For example all staff have recently completed a Safe Handling of Medication training course, and over three quarters of staff have a recognised care qualification- NVQ2. Staff also receive varied training to equip them with skills and knowledge to support residents. A rolling programme of training includes first aid, abuse and neglect, fire wardens, moving and handling, health and safety and physical intervention training. 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a service that is well-run by the manager, and by the systems of the organisation, which ensure that residents are central, and their views are valued and acted upon. EVIDENCE: The Home operates to West House’s Quality Assurance standards that includes the physical aspects of running the Home as well as monitoring the delivery of care. The provider, West House, appoints an operations manager to carry out Quality Assurance checks (regulation 26). These are sent into the Commission for Social Care Inspection on a monthly basis. From these reports areas for improvement are highlighted and this enabled the Inspector to check that actions had been taken to address these areas of improvement. These were 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 22 judged to work well in monitoring and improving the service for those living at the Home. The registered manager has the required qualification and experience, is highly competent to run the home and to meet its stated aims and objectives. The manager communicates a clear sense of direction, is able to evidence a sound understanding and application of ‘best practice’ operational systems, particularly in relation to continuous improvement, customer satisfaction, and quality assurance. The manager, in turn is ably assisted in this work by a qualified and competent senior support worker, and together they share areas such as staff supervision and appraisal. An area that highlights this thoroughness is the attention to detail in giving advice to staff in the moving and handling of residents. Staff are given clear instructions on all aspects of moving a person, for example from a chair to the bed, from a wheelchair to the bath, and on the use of hoists and other equipment that ensures both safety and dignity. The manager is a moving and handling trainer and regularly gives staff up-dates. The records examined on the day of the inspection were well-ordered, relevant, appropriate and up-to-date to assist in the smooth running of the Home and in meeting the needs of the residents. Health and safety measures are particularly thorough for example the home has just developed a new Fire Risk assessment, as required by a change in the law recently. 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 3 4 3 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 4 25 4 26 x 27 3 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 x 3 x LIFESTYLES Standard No Score 11 x 12 4 13 3 14 x 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 x 3 x x 3 x 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 24 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. Refer to Standard Good Practice Recommendations 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 3/4 Glebe Lane DS0000022557.V329081.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!