Inspection on 21/03/07 for 31 Liphook Road

This inspection was carried out on 21st March 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.

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

CARE HOME ADULTS 18-65 31 Liphook Road 31 Liphook Road Lindford Hampshire GU35 OPX Lead Inspector Pat Trim Unannounced Inspection 21st March 2007 10:00 31 Liphook Road DS0000068241.V324815.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 31 Liphook Road DS0000068241.V324815.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. 31 Liphook Road DS0000068241.V324815.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 31 Liphook Road Address 31 Liphook Road Lindford Hampshire GU35 OPX 01420 487309 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) Robinia Care Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 31 Liphook Road DS0000068241.V324815.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/A Brief Description of the Service: 31 Liphook Road is a care home for seven younger adults with learning disabilities. The home opened in August 2006 and is owned and operated by Robinia Care Limited, an organisation that has been a care provider since 1995. The home is in a quiet road in Lindford, Hampshire and it is easy to walk to the local shops from the home. Everyone has their own room with a bathroom. There are two lounges and a kitchen/dining room. The home has a garden at the back of the house for everyone to use. It costs from £1668.00 to £1900.00 per week to live in the home. Service users also have to pay for the hairdresser, newspapers chiropody, toiletries and annual holidays over £500. 31 Liphook Road DS0000068241.V324815.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Robinia Care Limited opened this home in August 2007 and at the moment only 4 people live there. This was the first inspection since the home opened. The inspection took one inspector 5.5 hours to do and all the key standards were looked at. During the visit the inspector was able to spend time with all the service users. She was not able to talk with them as she could not use the sign language they used to communicate. Time was also spent talking to the registered manager and 2 staff and looking at how service users and staff spent time together. Some time was spent looking at the home and at some of the records the registered manager has to keep. Before visiting the home, time was spent talking to the inspector who records any information we get about the home between inspections. More information for this report came from 2 comment cards, received from relatives and a pre inspection questionnaire, filled in by the registered manager and given to the inspector on the day of the inspection. What the service does well: Service users are supported to make choices about how they spend their time and staff make sure the home is run in a way service users like. The home is very relaxed and staff are very good at making sure service users do not get upset or bored. A lot of time is spent before someone moves into the home, making sure that 31 Liphook Road is the right place for them. Staff find out all about the person so that everything is ready for them when they move in. The home uses person centred planning to make sure that service users get support in the way they like it. They have lots of staff time so that they can go and do the things they like when they want to, such as bowling, swimming and going to clubs. 31 Liphook Road is a comfortable homely place where service users can spend time on their own or with others. Staff respect service users and help them to develop their skills. They are able to do this because they get a lot of training and support from Robinia Care Limited. 31 Liphook Road DS0000068241.V324815.R01.S.doc Version 5.2 Page 6 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. 31 Liphook Road DS0000068241.V324815.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 31 Liphook Road DS0000068241.V324815.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive pre admission assessments and trial periods ensure service users are only offered a placement if the service can meet their identified needs. EVIDENCE: The statement of purpose and service user guide included information about the admission process and informed prospective service users and their families, that a comprehensive assessment of need would be completed before the service user was offered a place. The home opened in August 2006 and four service users were currently living there. The process used to admit two of them was case tracked. Extensive information about each service user had been obtained prior to their admission. This included information from their current placements, from family and from social and health care professionals. A comprehensive assessment of need was completed by the regional development officer, which identified abilities, needs and potential areas of risk. A short-term care plan was completed prior to admission so that staff could offer appropriate support on admission. 31 Liphook Road DS0000068241.V324815.R01.S.doc Version 5.2 Page 9 The registered manager said it had not always been possible to arrange for service users to visit prior to admission. Where this was not possible, arrangements were made for staff to visit the service user and to spend time learning the service user’s daily routines, abilities and needs. One record showed that in excess of 10 visits had been made to the service user by staff prior to admission. The registered manager said that all the service users had a review of the placement carried out by adult services since their admission. A copy of one of these reviews was seen on file. During the inspection it was established that one service user was 17 years old. A transition plan had been put in place to facilitate his move into residential care and the statement of purpose identified that care could be provided to service users of this age. The certificate of registration did not record that service users aged 17 years could be admitted, although the registered manager was clear this had been requested at the time of registration. This issue is being dealt with separately from this report. 31 Liphook Road DS0000068241.V324815.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 good. This judgement has been made using available evidence including a visit to this service. Service users are well supported by service users’ plans that respond to their assessed needs. Service users are able to make decisions about their lives and to do activities supported by regularly reviewed risk assessments. EVIDENCE: Each service user had a comprehensive care plan that covered all aspects of personal, social and healthcare needs. The organisation uses person centred planning to make sure the service user’s own wishes and aspirations are at the centre of the support provided. Plans were clearly based on the information obtained in the assessment. For example, one assessment identified that a service user was frightened of dogs. The section of the care plan that related to going out, identified being near dogs as a potential risk and told staff what the likely response of the service user would be. It also gave clear guidance on how to manage the situation. . Care plans addressed cultural issues, ensuring staff were aware of individual needs in respect of diet and daily routines. The current service users have little or no verbal communication. Staff said they had been enabled to develop 31 Liphook Road DS0000068241.V324815.R01.S.doc Version 5.2 Page 11 the skills they needed to use each service user’s method of non-verbal communication and were observed using these throughout the day. They were seen supporting service users to make choices and responded quickly to requests. For example, during the day several service users demonstrated they wished to go out for a walk. Staff took them straight away. A variety of methods are used to ensure service users have the information they need to make choices about their daily routines. For example, staff were currently producing a picture board that had photographs of activities for one service user, as this had been found to provide him with the information he needed. Each section of the care plan included a risk assessment that identified any potential risks involved in the activity. It also identified the risks of not providing the support. For example, not helping a service user clean his teeth every day could result in gum disease or decay. Risk assessments were used in a positive way to enable service users to do activities they enjoyed. For example, risk assessments had been completed that identified how service users should be supported to go trampolining, swimming and bowling. The registered manager and staff said that all the current service users did sometimes display challenging behaviour. The care plan identified strategies for deflecting situations where challenging behaviour could occur. It also gave clear guidance on how to manage situations. All staff received training in using minimal intervention strategies. 31 Liphook Road DS0000068241.V324815.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 good. This judgement has been made using available evidence including a visit to this service. Daily routines promote independence and enable service users to take part in valued and fulfilling activities. Service users’ rights to access the community and maintain contact with families and friends are upheld by staff. Service users are offered a well balanced diet that provides them with a choice of meals that they like. EVIDENCE: The registered manager said that the home had links with a local college and service users were supported to attend, if they wished to do so. Each service user has allocated one to one time and this is used to provide support for individual activity programmes. Two service users are also able to go to the organisation’s day centre, where they have the opportunity to join in activities such as going bowling or rambling and socialising with service users from other homes. They may also 31 Liphook Road DS0000068241.V324815.R01.S.doc Version 5.2 Page 13 join in structured activities such as art, using the sensory room or developing their communication skills. On days when service users do not go to the day centre, they and staff decide how to spend the day. Staffing levels enable service users to make individual choices. For example, one service user likes to go to the pictures, whilst some of the others enjoy going for long walks. Some service users are able to use public transport, supported by staff, whilst others prefer to go out in the house car. Local services such as sports centres, clubs and pubs were visited regularly. Service users are able to choose how they spend their time in the home. Service users were seen watching their favourite films, making puzzles with staff or spending time alone in their rooms. Opportunities for more activities within the home are being developed. There are currently two lounges in the home. One has a television and the other is used as a quiet area. A small room is being converted into a sensory room and the registered manager said there were plans to turn one of the garages into an activity room. Staff work hard to maintain links with service users’ families. Individual care plans included guidance on how contact should be made. For example, one relative was contacted every day at a specific time and given information from the service user’s communication book about how he had spent the day. Another informed staff they should ring the relative, making sure the service user had their communication system with them. Staff then relayed what the service user was communicating to the relative. Comments from 2 relatives show that they are very satisfied with the contact they have with service users. • • • ‘A care worker always phones to let us know what’s been happening.’ ‘Every Friday we receive a call and after speaking with them, we get the chance to talk to our son – even though he can only listen.’ ‘Phone call from staff every week and they brought him to a party’. The registered manager said relatives were invited to reviews, provided the service user wished them to be there, and were welcome to visit at any time. Service users are supported to join in the daily routines of the home, but this is not clearly recorded in the care plans, or identified as something the service user wants to do. For example, service users help with meal preparation and doing their own laundry. This was discussed with the registered manager who agreed to include this information when each plan was next reviewed. 31 Liphook Road DS0000068241.V324815.R01.S.doc Version 5.2 Page 14 Staff were observed knocking on service users’ doors before entering and rooms can be locked by service users when they are inside. The registered manager said each service user could have a key to their room, but the current service users were not able to use them. Staff ensured individual bedroom doors were locked when the service user was out. The registered manager explained that due to the behaviour of one service user the communal toilets and kitchen were kept locked. Service users had to ask staff to let them into these areas of the home, but could use the facilities in their en suites at any time. The registered manager said this practice was being kept under review and it was hoped that it would eventually become unnecessary. An individual record is kept of the choices service users make about meals. The weekly menu showed a varied and balance diet was provided. The registered manager said service users choose their meals and take it in turns to go shopping for the weekly supplies. Service users are also supported on an individual basis to help with meal preparation. Two service users have specific needs in relation to food and staff ensure these are met. Staff were aware of the cultural needs of service users and ensured appropriate food was available at all times. One relative felt service users had good meals, but another thought the variety could be improved and that more fresh fruit and vegetables could be served. 31 Liphook Road DS0000068241.V324815.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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. The physical and emotional health needs of service users are well met with evidence they may access a wide range of health services. The medication system at the home is well managed, which protects service users. EVIDENCE: Care plans recorded in great detail how service users liked to receive their personal care support. They showed what service users could do for themselves and whether they needed prompting or physical support. For example, the routine required for one service user to clean his teeth and another to have a shower was described stage by stage. Staff said they were required to read the care plans as part of their induction and they were continually reviewed at staff meetings to ensure everyone felt they reflected the individual likes and needs of the service user. Staff were able to describe what support service users required and what they could do for themselves. For example, a member of staff describing the service user he was key worker to stressed that he liked and needed to be able 31 Liphook Road DS0000068241.V324815.R01.S.doc Version 5.2 Page 16 to make choices. He said he liked to choose his own clothes each day and when he did specific activities. Initial assessments identified any health care issues and evidence was seen that appropriate referrals were made to address these issues. For example, one assessment identified a service user had a specific need in respect of developing communication skills. A referral had been made to speech and language therapy for support and advice. Records kept of referrals to health care professionals demonstrated that service users were able to access a wide range of health care support. Comments from 1 relative indicated that staff are developing good observational skills as they had noticed when the behaviour of a service user was unusual and thought it could mean he was unwell. Medical support was requested. The medication policy of the home stated that only trained staff could give out medication. Staff confirmed this was correct and training records showed staff responsible for managing medication had received relevant training. The home had systems for recording what medication came into the home and any that was returned. Records of medication administration were well maintained and up to date. Two staff are required to administer medication. Medication was stored appropriately in a locked cupboard. There was a facility for storing controlled medication. The home has a policy that supports service users to manage their own medication, but the registered manager said current service users had been assessed as not able to do this and staff supported them to take it. 31 Liphook Road DS0000068241.V324815.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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a system for recording and responding to complaints in a format that helps service users understand the process. The home has suitable procedures in place to protect service users from abuse and staff receive training that enables them to have a good understanding of adult protection issues. EVIDENCE: The home had a complaints procedure and information about it was included in the statement of purpose and service user guide. The service user guide was provided to each service user in a pictorial format. Service users have access to information about advocacy services and the home has contact with the local advocacy group. There was a system in place for recording complaints. The registered manager and the commission had not received any complaints about the service. Service users’ views, ideas and concerns are discussed in monthly house meetings. Service users also take it in turn to represent the home as part of the organisation’s “Client Forum” which is held at the main office bi-monthly. The home has an adult protection policy and procedure in place and staff spoken with had a good understanding of them. Evidence was seen that all staff received adult protection training. 31 Liphook Road DS0000068241.V324815.R01.S.doc Version 5.2 Page 18 Records for the management of service users’ personal allowances were seen and assessed as well maintained. The registered manager said that some service users were supported to get their own money from the bank when they needed it. 31 Liphook Road DS0000068241.V324815.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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to live in a clean and well maintained environment that meets their needs. There are systems in place that protect service users from the risk of infection. EVIDENCE: The home has two lounges and a kitchen/dine, which have been thoughtfully furnished to meet the needs of service users, whilst maintaining a domestic environment. As stated in the ‘Lifestyle’ section of this report, there are plans to develop the environment further to meet the needs of service users. A small room is being turned into a sensory room and a garage into an activities room. The environment is quite bare at present. The registered manager explained this was intentional as it was the expectation that current service users would 31 Liphook Road DS0000068241.V324815.R01.S.doc Version 5.2 Page 20 choose how the home was decorated and items were beginning to be purchased to reflect their choices. All service users have their own bedroom with an en suite. Their rooms are furnished with their own possessions and are bright and airy. There is a garden at the rear of the property, reached by double doors from the dining area. This has a patio and the registered manager said there were plans to purchase tables and chairs so that service users could use this area when the weather improved. The home was clean, hygienic and free from offensive odours. The laundry has a washing machine with a programme for the disinfecting of soiled linen and has been decorated so that it can be easily cleaned. As already discussed in the ‘Lifestyle’ section of this report, service users are encouraged to help with doing their own laundry. Each person’s laundry is washed separately. The home does not have to dispose of clinical waste. 31 Liphook Road DS0000068241.V324815.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): 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. Recruitment practices protect people living in the home. Staff receive appropriate training to enable them to meet the needs of residents. EVIDENCE: The home has a core staff of 8 people. 50 of these have completed a National Vocational Qualification (NVQ) 2. Two staff were spoken with during the course of the inspection. Both had previous experience of working with service users who have a learning disability, and had completed various training courses prior to joining the organisation. Feedback from 2 relatives of service users was positive about the skills of staff, stating • ‘Generally they seem competent and well informed’ DS0000068241.V324815.R01.S.doc Version 5.2 Page 22 31 Liphook Road • • ‘There is a mix of people within the home which is good.’ ‘Most staff are adequately trained’. Two staff were case tracked to look at the recruitment process. Both had been required to complete an application form, provide two references, attend an interview and provide evidence of qualifications and training. Both had criminal records bureau (CRB) and protection of vulnerable adults (POVA) checks completed prior to their employment. The registered manager said all staff were expected to complete a recognised training course in working with learning disability and completed workbooks for two staff were seen. Robinia Care Limited has a designated training officer who co ordinates training opportunities and refresher courses. Records seen showed that all staff are provided with training in health and safety, communication, autism, deescalation of unacceptable behaviour, epilepsy, medication assessments, moving and handling, first aid, and food hygiene. Staff spoken with informed the inspector that they feel well supported in receiving appropriate training. Training needs are discussed and reviewed as part of regular supervision. 31 Liphook Road DS0000068241.V324815.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, 39, and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and staff benefit from there being competent manager in post. Service users live in a safe environment and benefit from being involved in an appropriate quality assurance system. EVIDENCE: The manager has been in post since the home opened and was registered by the commission in February 2007. He has completed a National Vocational Qualification (NVQ) 4 in care and is starting a registered manager’s award shortly. He has worked for the organisation for 6 years and prior to that worked in a range of social care settings. Staff said he was very approachable and had an open and transparent style of management. Service users were seen going to his office throughout the day 31 Liphook Road DS0000068241.V324815.R01.S.doc Version 5.2 Page 24 and he spent a large part of his time with them and monitoring their care. Comments received from 2 relatives confirmed they felt the home was well managed, communication was good, and issues raised dealt with efficiently. The atmosphere was relaxed indicating an environment where service users’ abilities and aspirations are being promoted. Comments from relatives included • • ‘The home exceeds our expectations’ ‘Staff act in the interests of service users and not their own convenience’. A quality assurance system based on seeking the views of residents, relatives, service purchasers and professionals is in place. A monthly audit of the service is carried out by a representative of Robinia Care Limited and the registered manager said he is required to send a monthly report to the provider. Resident meetings are held monthly in the home, which are recorded. Some service users also belong to a forum and join service users of other local care homes operated by Robinia Care Limited to discuss possible improvements. The pre inspection questionnaire provided a list of service and maintenance contracts. This, together with copies of service contracts seen during the inspection, such evidence the registered manager ensures the environment is well maintained and all equipment regularly serviced. Staff said they received training in all aspects of health and safety. Records seen showed they completed basic training such as food hygiene, moving and handling and first aid. The registered manager said he was sent a list of all training completed by staff on a monthly basis and used this to identify training needs during supervision. 31 Liphook Road DS0000068241.V324815.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 31 Liphook Road DS0000068241.V324815.R01.S.doc Version 5.2 Page 26 N/A 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 31 Liphook Road DS0000068241.V324815.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 31 Liphook Road DS0000068241.V324815.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. 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