Inspection on 08/06/07 for 3 Water Meadows

This inspection was carried out on 8th June 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 Water Meadows 15/02/06

3 Water Meadows 25/10/05

3 Water Meadows 24/11/04

3 Water Meadows 21/07/04

3 Water Meadows 23/02/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 3 Water Meadows 3 Water Meadows Cullompton Devon EX15 1QS Lead Inspector Louise Delacroix Key Unannounced Inspection 8th June 2007 10:20 3 Water Meadows DS0000021846.V335059.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 Water Meadows DS0000021846.V335059.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 Water Meadows DS0000021846.V335059.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3 Water Meadows Address 3 Water Meadows Cullompton Devon EX15 1QS 01884 34287 01884 836229 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) The Disabilities Trust Mrs Christine Mary Chitty Care Home 2 Category(ies) of Learning disability (2), Physical disability (2) registration, with number of places 3 Water Meadows DS0000021846.V335059.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2006 Brief Description of the Service: 3 Water Meadows is a three bedroomed house situated in a residential area of Cullompton. The house has a lounge, a kitchen / dining room and a toilet on the ground floor and on the first floor there is a bathroom/ toilet, two bedrooms and an office/sleep-in room. There is garden at the front of the property and a small-enclosed garden to the rear. The home provides rehabilitation care for two people who have an acquired brain injury. The staff support people to re-establish their independent living skills and the home is seen very much as a step onwards for people from The Woodmill, which is the main unit situated not far from the home. Prospective service users may also come from their own homes after a detailed preadmission assessment. Whilst the home has its own staff team it is also able to make use of the multi-disciplinary staff team based at The Woodmill. The weekly cost is £1262.50, with additional charges for chiropody, hairdresser, toiletries, newspapers/magazines, activities and travel. 3 Water Meadows DS0000021846.V335059.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and lasted three hours at the home, with a further hour spent at The Woodmill (another BIRT home) where staff recruitment and training files are kept and the registered manager is based. Both of the people living at the home were present and played a key role in contributing to the inspection. Time was also spent talking with two members of staff and the registered manager. Medication, staff recruitment and training files, maintenance records, personal allowance files for people living at the home, and plans of care were looked at. The Commission for Social Care Inspection (CSCI) asked for the home to send out a range of surveys published by the Commission to gain feedback from people in contact with the service. One relative and one health professional responded. Surveys were also sent to the small staff team and the people living at the home. All responses have been included in the report, as has details from the home’s pre-inspection report, which gives details about the service and is completed by the registered manager. What the service does well: No new people have moved to the home since the last inspection but there are good systems in place to ensure that people are enabled to visit before moving in, given appropriate information about the service, with a thorough assessment process to ensure that the home can meet their identified needs. People living in the home feel involved in their plans of care and actively choose their own personal goals. Staff are in tune with these goals and work beside people to achieve them. People living at the home make decisions about their lives and are provided with suitably formatted information to enable them to do this. The service recognises this can involve risk taking, and works towards addressing these in a skilled and creative way. People are supported to keep in touch with families and make links with the local community. Within the home, there is clear ethos that people have the right to privacy and independence. People living at the home have a strong sense of being involved in the running of the home. The home has strong links with health care services and ensures that peoples’ health care needs are met, by a high quality of monitoring and support that reacts to changes. Medication is also well managed. Staff are clear about their role to safeguard the people living at the home, and their responsibility to report poor practice. The systems within the service ensure that service users’ finances are well managed and safeguarded. 3 Water Meadows DS0000021846.V335059.R01.S.doc Version 5.2 Page 6 The environment of the home is maintained to a high standard whilst retaining a comfortable feel. The atmosphere throughout the inspection was relaxed and friendly, with both people living at the home appearing at ease and comfortable in the homely environment. Staff are well inducted, supported and supervised. The organisation provides a good range of training, including mandatory and specialist, which is regularly updated. The home is well managed with service users and staff having regular access to the manager. There are systems in place, which enable people to influence the way the service is run and to express their views. There are regular safety checks, and unannounced visits by different members of the management to monitor the quality of the service. What has improved since the last inspection? 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 Water Meadows DS0000021846.V335059.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 Water Meadows DS0000021846.V335059.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): We looked at standards 2,4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are actively involved in the decision to move to the home and are involved in setting the goals in their care plans, which help staff to meet their needs and aspirations. EVIDENCE: The home calls itself a “near reach house” with the goal of working towards the service user eventually moving on to more independent living. The team at the brain injury unit carries out full assessments and then with the service user creates a treatment and rehabilitation programme. The team consists of care workers, occupational therapists, physiotherapists, psychologists and GP’s as necessary. Assessments from social care professionals, i.e. care managers also play an important role within the assessment. People living at the home and staff confirmed how a new person was introduced to the home and to the current resident over a period of time. This was also confirmed by care records and involved support from The Woodmill team as well. Both people living at the home already knew one another. 3 Water Meadows DS0000021846.V335059.R01.S.doc Version 5.2 Page 9 One of the people living at the home had signed their contract, which contained all the required information i.e. notice period. 3 Water Meadows DS0000021846.V335059.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): We looked at standards 6,7,9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care needs are well met in an individual manner by caring and informed staff. The ethos of the home promotes the rights of people living there to make choices in their lives, and to be involved in setting the goals they wish to achieve. EVIDENCE: Plans of care are generated from detailed assessments and have a holistic approach to the lives of the people living at the home. They are well worded and sensitively portray how support should be provided that recognises the person’s strengths and areas for development. The plans of care acknowledge that the success of support relies on the person living at the home being in agreement with the approach. This was apparent from discussion with the house leader, and a separate discussion with one of the people living at the home. 3 Water Meadows DS0000021846.V335059.R01.S.doc Version 5.2 Page 11 Plans of care include clear guidelines regarding communication and risk assessments relating to restrictions on activities. People living at the home spoke about their goals, which were reflected in their care records and through discussion illustrated their involvement in decisions. These also evidenced the multi-disciplinary approach to support people’s goals i.e. a communication class. Plans of care also reflect changes in people’s lives. One person spoke about their move to another BIRT home in Exeter. They were very positive about this change, and there was a strong sense of involvement in the plans. Staff were also clear about these plans, and were supportive in their attitude and in their discussions with and about the individual. Care records show the views of people living at the home. People living at the home explained, as did a staff member, that they are provided with opportunities to make decisions about their lives either through reviews or informally on a day-to-day basis i.e. choosing meals. In their surveys, one person felt this was always the case, and the second person felt this was usually the case. The minutes from reviews evidence that people living at the home are able to attend and contribute to these meetings. These reviews are held at appropriate intervals. A health professional that has long standing links to the home said that the service always supported individuals to live the life they chose. One plan of care had an example where an occupational therapist from BIRT had written a letter about an activity that the service user had been involved in. It clearly stated the pros and cons linked to the activity, to help enable the person to make an informed choice. Plans of care, and discussion with staff and people living at the home, clearly show that risks and hazards are openly discussed and recorded. Daily records show the staff team’s awareness to monitor progress and help achieve identified goals. The home benefits from a multi-disciplinary team approach, which helps ensure a creative and skilled approach towards risk taking. The home’s missing person’s policy has clear steps for staff to take, which also includes informing CSCI. A range of professionals contributes to the risk assessments with multi-disciplinary advice whilst also identifying training that is needed for the person’s personal safety. People living at the home were also clear about specific risks to them and talked about how these were managed. 3 Water Meadows DS0000021846.V335059.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): We looked at standards 12,13,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living at the home are supported to reach their individual goals and fulfil their potential by staff who respect them. Meals at the home suit the individual tastes and needs of the people living there. EVIDENCE: People living at the home explained that they weren’t currently involved in a work placement but spoke about their ability to access courses related to their own interests or self-development. One person felt they would prefer to have more stimulation. Staff were aware of this wish, and care records showed that the person was being supported by a multi-disciplinary team to recognise their role in achieving this goal. A relative commented in their survey that the home supported people to live the life they choose whenever possible, and recognised that the care home ‘tries very hard to rehabilitate’ people with a brain injury. 3 Water Meadows DS0000021846.V335059.R01.S.doc Version 5.2 Page 13 Records and discussion with staff confirmed that people living in the home choose whom they mix with socially, and that they are supported to maintain contact with family with recognition of their communication needs. Both people felt that they were supported to see their family, which was important to them. A relative said the care home always helped the person living there keep in touch. Records also showed people being supported to remember significant birthdays and to buy presents. People living at the home spoke about how they were supported to continue with their interests, which includes bird watching, pottery and art classes. From talking with people living at the home, it was clear that they felt able to indicate when they wanted company or privacy, and this was observed during the inspection. One person has a key to the home while the other person has been risk assessed as this being an unsuitable option. Staff were seen respecting people’s privacy throughout the inspection, and records demonstrated a careful balance of care and independence in the monitoring of a people’s health and safety. There was a clear sense of each bedroom belonging to each individual, while people living at the home answer the door showing a sense of ownership. People spoke about how they made decisions about what they ate. Care records recognised their individual likes and dislikes, and listed a record of a variety of meals, which reflected these tastes. There was recognition of motivating people living at the home, and clear guidance to staff about how to achieve this. One person spoke about enjoying tasks around the home and sharing responsibilities for meal preparation. During the inspection, a meal took place with the care staff offering guidance and advice where necessary. Staff could be heard offering support in a respectful but also lighthearted manner, which both people seemed to appreciate, resulting in laughter. 3 Water Meadows DS0000021846.V335059.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): We looked at standards 18,19,20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service provides excellent support and care, which reflects the individual, physical and emotional needs of the people living at the home. People’s health needs are protected by good medication practice, and good access to health care services. EVIDENCE: Plans of care contain individual and clearly written guidelines about supporting people with personal care, which recognise individual choice, and provide advice for staff about a sensitive approach. For one person there has been a creative approach to supporting them with a shower, and thought given as to who assists them. Daily notes about personal care are written appropriately. Small adaptations have been made to the environment to maximise people’s independence following assessments by the multi-disciplinary team, which includes occupational therapists. When new items are bought for the home, consideration is given to design, which will help enable people living there e.g. a new shower with clear instructions and advice on water temperature. 3 Water Meadows DS0000021846.V335059.R01.S.doc Version 5.2 Page 15 Staff showed a good understanding of the health needs of the people living at the home. There was evidence in care records of good links with other health care professionals e.g. GP, chiropody, psychologist and dentist, and ensuring that service users receive the health care they need. Records are in place to monitor people’s health, motivation and mood with reviews taking place to address the outcomes, and where necessary personal goals are amended in discussion with the person. People living at the home talked about their disabilities and health needs and how they were supported with these. A GP said in their survey that the care staff always have the right skills and experience to support individual’s social and health care needs. Medication is appropriately stored, recorded and checked in, with written additions double signed, which is good practice. A member of staff spoke about a resident’s medication demonstrating their awareness of the resident’s health issues, and the staff member’s responsibility to respond to this. Guidelines were clearly written and informative. A GP said medication was always managed correctly. People living at the home have been asked about their last wishes, and records show that both people were fully involved in this discussion. These have been updated and are sensitively written. 3 Water Meadows DS0000021846.V335059.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): We looked at standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are safeguarded by well-informed staff and well kept records. EVIDENCE: The home has a comprehensive complaints procedure, which has also been produced in a format suitable to the needs of the people living there. There have been no complaints at the home since it has opened. Neither person living at the home wished to raise any concerns during the inspection. Both were clear about who they would go if they had a complaint. A visitor to the home said they knew how to make a complaint and said that if they had raised concerns they were always responded to appropriately by the service, which was confirmed by a health professional. No complaints have been received by CSCI about the service. Staff explained that people living at the home are supported with their finances after a risk assessment. Receipts are kept, with credits and withdrawals signed for within clearly kept records. A spot check evidenced that financial records were well kept and correct, so that transactions could be audited. There are clear guidelines within individuals’ care records about how staff should respond to possible verbal or physical aggression. The Brain Injury Trust provides a thorough in-house training programme for staff, which includes vulnerable adult training, including the induction programme. A 3 Water Meadows DS0000021846.V335059.R01.S.doc Version 5.2 Page 17 member of staff spoke about their understanding of their duty to report poor practice, and were clear about contacting both internal management and external agencies to report concerns/allegations. Staff files show that appropriate safeguarding training has taken place for new members of staff, including the provision of the home’s policies on protection of vulnerable adults and whistle-blowing, which details staff responsibility to report poor or abusive practice. Staff had signed these. 3 Water Meadows DS0000021846.V335059.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): We looked at standards 24 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The maintenance and décor of the home is maintained to a high standard, and provides a clean and homely atmosphere for people living there. EVIDENCE: The home blends in with the neighbouring houses and is walking distance from Cullompton High Street. Each person has a single room, and they have use of all other parts of the home, apart from the office/sleep in room. There is a communal domestic sized bathroom and a downstairs toilet. There is a separate lounge with a kitchen/diner. The home is decorated in an attractive style, and is well maintained, clean and odour free. People living at the home are asked about the décor, and recently a member of staff used paint match pots so people could contrast the colours and choose their favourite. One of the people living at the home talked about their work in the home’s garden and showed a sense of pride in this role. A member of staff has brought 3 Water Meadows DS0000021846.V335059.R01.S.doc Version 5.2 Page 19 in plants from home for the front garden, and the back garden is well looked after. This attention to detail helps the home blend into the neighbourhood. Furnishings are of a good quality with fixtures and fittings regularly updated and to a high standard. Minor adaptations have been made to accommodate the physical needs of the people living at the home i.e. grab rails. There is a planned maintenance and renewal programme for the home, which includes plans to re-carpet the lounge and hall. Since the last inspection, a new television has been bought and a new shower fitted. 3 Water Meadows DS0000021846.V335059.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. JUDGEMENT – we looked at outcomes for the following standard(s): We looked at standards 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a small committed staff team, who are generally well recruited and whose training opportunities and skills benefit the people living at the home. EVIDENCE: People living at the home said that staff listened to them and spoke positively about the team, although one person felt that some staff had too much paperwork to do. Discussion with two members of staff showed an appreciation of the individual needs of each person living at the home, and their backgrounds, plus knowledge of their specific disabilities. A staff recruitment file was looked at, which showed that the correct Police checks were carried out prior to the person starting work, with suitable identification supplied. There had been a delay regarding one reference, and although the registered manager had ‘chased’ the response, this was not logged, which would have been good practice. A member of staff spoke about their induction programme, which they described as full and comprehensive. They also explained that they had visited 3 Water Meadows DS0000021846.V335059.R01.S.doc Version 5.2 Page 21 the home and met with people living there before beginning work, including shadowing different shifts with an experienced staff member. They described the atmosphere as supportive, with members of staff and management being informative and approachable. Staff records show a range of mandatory training is provided including health and safety and medication administration, plus specialist training in brain injury. In response to the CSCI survey, staff spoke positively about regular planned supervision, and at least once a week visits from the manager, although these are not always recorded in the visitors’ book. Staff spoke of having their work observed and having the chance to meet as a team. One person described it as ‘a good place to work at and generally achieves its aims’. 3 Water Meadows DS0000021846.V335059.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. JUDGEMENT – we looked at outcomes for the following standard(s): We looked at standards 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. This is a well-managed service that has processes to ensure that people living in the home are consulted about the service. Health and safety is managed well at the home, and one minor improvement will further protect the people living there. EVIDENCE: The house leader manages the home on a daily basis supported by the registered manager, who is based at The Woodmill. In discussion, staff were clear about the lines of responsibility, and confirmed that the registered manager has regular contact with the home and was approachable. Discussion with the registered manager about the people living at the home and issues related to the service demonstrated an up to date knowledge. The registered 3 Water Meadows DS0000021846.V335059.R01.S.doc Version 5.2 Page 23 manager continues to up date her professional training and has regular contact with the people living at the home. Staff explained that house issues are discussed informally with people living at the home. The house leader then discusses the outcome or issues with the clinical team based at The Woodmill. The house leader then feeds back the responses/action from the meeting. People living at the home said that they prefer this informal approach. Review minutes also evidence that service users can put forward their viewpoint or ask for a representative to do this on their behalf. People living at the home are also given the opportunity to meet with management on an informal basis. The home’s accident records are completed appropriately, and water and fridge/freezer temperatures are monitored. Staff records show that they receive regular fire training, which was confirmed by a member of staff. The home’s pre-inspection questionnaire shows that safety checks are up to date. Staff confirmed that a member of staff from The Woodmill (another Brain Injury Trust home) visits on a weekly basis to over see safety and maintenance checks. Staff also confirmed that regulation 26 visits happen on a monthly basis to audit the quality of the service. However, one bedroom radiator does not have a guard and at the present time, a piece of furniture only partially obscures the radiator. The bathroom radiator does not have a guard on it despite one person recently falling in this area. The manager said a risk assessment had been completed previously but this could not be found on the day of the inspection. 3 Water Meadows DS0000021846.V335059.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 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 2 35 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 4 x LIFESTYLES Standard No Score 11 4 12 3 13 3 14 x 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 3 3 x 4 x x 2 x 3 Water Meadows DS0000021846.V335059.R01.S.doc Version 5.2 Page 25 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. 1. Standard YA42 Regulation 13 (4)(c) Requirement A risk assessment for individual uncovered radiators in the home must take place, and action taken to guard the radiator if the risk is medium or high. Timescale for action 08/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA34 Good Practice Recommendations Where there are delays in staff references, contact with referee should be recorded, and where another referee has been chosen the reason should be logged. 3 Water Meadows DS0000021846.V335059.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Water Meadows DS0000021846.V335059.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. 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