Inspection on 01/06/07 for 4 West Street

This inspection was carried out on 1st 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

4 West Street 01/12/06

4 West Street 22/12/05

4 West Street 18/05/05

4 West Street 29/09/04

4 West Street 03/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 4 West Street, Biddulph Staffordshire ST8 6HL Lead Inspector Mr Berwyn Babb Unannounced Inspection 1st June 2007 02:45 4 West Street, DS0000029679.V339492.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 4 West Street, DS0000029679.V339492.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. 4 West Street, DS0000029679.V339492.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 4 West Street, Address Biddulph Staffordshire ST8 6HL 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) 01782 514141 Choices Housing Association Limited Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 4 West Street, DS0000029679.V339492.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: 4 West Street was registered in March 2002 to accommodate four younger adults with learning disabilities. It is a large detached bungalow, which has been extended to provide suitable accommodation, including 4 single bedrooms, a spacious bathroom and a walk in shower room. Communal space includes a large lounge and a kitchen/dining room. The service also provides a separate laundry and large storeroom housing the food freezer and other household items. Externally there are good-sized gardens and a patio area, all are accessible to service users. A large garage is used for storage purposes, the drive way provides parking space. The home is located in the village of Biddulph, within a short walk from the main shopping area, local pubs, church and other facilities. 4 West Street, DS0000029679.V339492.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place on the afternoon of Friday the first of June 2007 and was carried out by one inspector. The person who has been appointed to be the manager (awaiting CSCI approval as a fit person) was not on duty, and the home was in charge of the deputy manager. Two carers/support workers were on duty at all time between 7:30 a.m. and eight oclock at night, after which one person was watchful waiting until 11 oclock, and then officially on Sleep In duty until 730 next morning. Three of the four people who use the service were in the home for the duration of the inspection, and they all took part and interacted with the inspector. The fourth person unfortunately was detained in hospital at this time, and a review of her medication was being undertaken to see if this could be changed to bring about an improvement in her challenging behaviour. Members of staff were busy making arrangement at the commencement of the inspection to ensure that she received a daily visit from one of them. Evidence was gathered from documentation, from observation during a tour of the premises (both internally and externally), from discussions with the deputy care manager and other members of staff, from a formal interview with one member of staff, and from discussion and interaction with people who use the service. The home was clean, warm, tidy, and decorated and furnished to a good standard, and nothing was seen during the inspection to cause concern or necessitate the making of any requirements. Fees for accommodation at 4 West St are given as currently being:£919 to £961 per week. What the service does well: This home continues to provide the most domestic style of accommodation possible for four persons with a learning disability. It does this in a neighbourhood community, without in any way being stigmatised as a care institution. 4 West Street, DS0000029679.V339492.R01.S.doc Version 5.2 Page 6 It supports the people who use the service to be as independent as they can be with regard to reality and safety, and seeks to maximise their potential by enabling them to have a fulfilled life. 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. 4 West Street, DS0000029679.V339492.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 4 West Street, DS0000029679.V339492.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. The quality outcome for this group of people who use the service was This judgment was made using all available evidence including a visit to the service. The individual needs and aspirations of perspective users of the service were being assessed, so that nobody would be admitted inappropriately, and people would be reassured that they were not going to have to move again, to receive the care and support they needed. EVIDENCE: The updated service users guide provided information in a very accessible format regarding the process of pre-admission assessment, and the provision of a written confirmation that the needs and choices of the person concerned could be met by the home. The document was well populated with easy to follow picture images to make the subject matter clear to anybody who was unable to read and written English. 4 West Street, DS0000029679.V339492.R01.S.doc Version 5.2 Page 9 Discussion with a member of staff pointed the Inspector to the care plan of one of the people who use the service, where he was able to see that prior to admission that he had been involved in an expanding programme of visits to the home, culminating in an overnight stay which helped the prospective resident to be reassured that she would fit in with the existing group of people, and would not be distressed by receiving care from the staff members (the majority of whom attend the home at one time or another during such a visit, to meet the prospective user of the service). 4 West Street, DS0000029679.V339492.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. The quality outcome for this group of people who use the service was good. This judgment was made using all the available evidence, including a visit to the service. People who use the service were seen to have a comprehensive Person Centred Plan of their changing needs and personal goals that would allow them to receive the care they needed in the most appropriate manner, including support to make decisions about what they did, and to take risks associated with maximising their potential. EVIDENCE: The three people who use the service in the home at the time of the inspection were all spoken to throughout the course of the inspection. (The fourth person was in hospital for a period of assessment and treatment and members of staff were arranging who should visit her that afternoon as the home likes to keep very close contact with people when they are not in the home. 4 West Street, DS0000029679.V339492.R01.S.doc Version 5.2 Page 11 They spoke about the things that they have helped to do each day, or and negotiation was observed between them and members of staff over implementing some of their chosen activities. They were assisted to consider the implication of responding to impulsive desires, especially in relation to how they spent their money, and how they would feel if they bought everything that they saw, and then finished up with insufficient funds for the purchases they have been used to making regularly. Reference to care plans showed that this was part of an ongoing programme with one individual to ensure continued satisfaction from having a reasonable reserve of savings at their disposal. Discussion with members of staff further pointed to a continuing awareness through the care planning process, of the need for one persons impulsive responses to a deeper consideration of their language, thus protecting them from the likelihood of causing embarrassment and annoyance to members of the opposite sex when out in public. Staff sensitively explained the risk of social isolation to the person who used the service, should they continue to make remarks of a personal nature without considering the effect on the other person. Discussion took place with the person in charge of the home about the input of outside health professionals to assess ways in which people use the service could be supported to carry out their chosen activities without undue risk, including the provision of training, monitoring, and personal support, when needed. 4 West Street, DS0000029679.V339492.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. The quality outcome for this group of people who use the service is good. This judgment was made taking into account all available evidence including a visit made to the service. People whom use the service was seen to be enabled to engage in occupation and/or education that was appropriate to their age, status, and cultural background. They engaged with the community, and maintained relationships and friendships, and in the daily routines of the home had their rights and responsibilities respected, including the provision of an enjoyable, nutritious, and sufficient diet. EVIDENCE: There was a very strong statement in the service users guide championing the right of the person who uses service to have access to the community at all appropriate times. 4 West Street, DS0000029679.V339492.R01.S.doc Version 5.2 Page 13 Discussion about access to education and occupation within the community centred around two of the people use the service who not only go to college on different days to attend both educational courses and arts and craft sessions, but also undertake therapeutic earnings at the headquarters of the providers, where they assist with keeping the filing system up-to-date. One of these ladies has been expanding her interest in her pottery class by continuing to make things for decoration when she returns to the home. A third lady, who was not in the home of the time of inspection, has a schedule of the drama classes at college once a week. Another person who uses the service exercises their religious choice by going to church every Sunday morning, and widened the friendships begun there, by attending the church run luncheon club on Wednesday. This person was particularly pleased to be able to take the inspector on a tour of the home, pointing out items of personal significance. Record was seen in the Person centred care plans of trips out to a local park to feed the ducks, to people who use the service going to Chester zoo the following week, holidays in a caravan which the providers have established at the North Wales seaside resort of Rhyll, regular trips to the library, sports Centre, and pubs and restaurants for both meals out, and a drink. In addition to this all residents had been issued with a pass, which allowed them to visit the local National trust property free of charge. One of the residents spoke about a long-term friendship she had with somebody you used another of the services provided by the Choices organisation, and how they had regular contact including a recent day trip to Blackpool. Another person who uses the service recounted the recent visits to and from members of her own family, and the concern about one of her sisters who currently is not very well. A visit to the kitchen demonstrated that there were sufficient supplies to provide a variety of meals as per the collected choices of the people who use the service, and there were appropriate records for fridge and freezer temperatures, and pf deeper and more regular, cleaning programs. 4 West Street, DS0000029679.V339492.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, on 20. The quality outcome for people who use this service in this area is good. This judgment was arrived at using all the available evidence including a visit to the service. People who use the service was seen to receive comprehensive social and Healthcare support in line with their assessed needs and choices, and their programs were seen to have been regularly reviewed so that they could experience the best possible levels of both emotional and physical health. EVIDENCE: The service uses a guide makes a very strong commitment to the right of people who use the service to be consulted about any therapeutic interventions that are deemed necessary to maintain their health, whether that be in relation to a long-established condition, or to any newly emergent concern. 4 West Street, DS0000029679.V339492.R01.S.doc Version 5.2 Page 15 In a formal interview a member of staff described how she would assist one of the people who use the service to take a bath. In addition to showing awareness of the practical concerns over health and safety issues associated with this task, she demonstrated a concern for the dignity and independence for the person in her charge, and a detailed knowledge of how they liked to be assisted and supported, and the things that they both wanted and were able to do for themselves. She also appreciated the importance of this task into other areas. Firstly, to allow the person who uses the service time to relax in a warm and comforting environment (to have a soak) and secondly, as an opportunity to enable a person to have some safe space in which to talk about things that they may be inhibited in bringing up in more public arena of the home, outside the sanctity of the bathroom. Discussion with the person in charge of the home touched on the quality of support and advice available from statutory health care professionals, and mention was made of a Community Psychiatric Nurse, who had been very helpful and had facilitated further input for one of the two people she visited in the home, so that they could benefit from both occupational therapy, and physiotherapy. The staff were less happy than one about having needed to obtain the services of a doctor who was unknown to one of their ladies, when she had unfortunately needed to be detained under the Mental Health Act. For reasons that were not made known to the inspector, nobody from the surgery where that lady was registered was available, and the task had to be undertaken by someone who had neither personal knowledge, or access to the medical notes of the lady. The only positive aspect of this admission to hospital has been at a wholesale review of her medication can be carried out while she is the subject of 24-hour observation by fully qualified medical staff. Less rigorous medication reviews were undertaken by the local GP surgery during involvement in the Well Woman and Well Man annual health checks. The results of these were documented under the review sections of the personal care plans of each individual in the home, and reference to these established that currently there is nobody in the home who administers any of their own medication. The matrix of training undertaken by members of staff demonstrates that all people who administer medication have been appropriately trained to undertake this task. During the course of the afternoon staff were observed to be skilfully working to ensure that good personal dynamics where maintained between the people who use the service, and between them and the wider community, and this was most apparent in their concern to see that nobody stigmatise themselves by behaving in a way that was unacceptably inappropriate. People were never corrected, but were gently redirected, and the way this was done without endangering the harmony of the establishment was a tribute to the experience and skill of those people employed in the home. 4 West Street, DS0000029679.V339492.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. The quality outcome for this group of people who use the service is good. This judgment was made using all the available evidence including a visit to the service. People who use the service was seen to have their rights protected by staff that had been well-trained, and to be accommodated in a home that had policies and procedures specifically designed to ensure that they were protected from abuse, and that their voice would be heard should they be concerned about anything. EVIDENCE: One of the principal statements in the service uses guide clarified to people using the service their right to have an advocate. Both in writing and in easy to understand picture format, it stated the commitment of the home to ensure that someone would speak up for them, if they were not being heard. It also reinforced that if they were not happy about anything, theyre absolute right to have somebody to talk to about this. There have been no complaints received regarding this service to Commission for Social Care Inspection, and those recorded in the file kept at their home of complaints and grumbles made to them, had been appropriately responded to. 4 West Street, DS0000029679.V339492.R01.S.doc Version 5.2 Page 17 In a formal interview with a member of the care staff, reference was made to the subject all the protection of vulnerable adults, and she was able to demonstrate a comprehensive awareness of the range of people (anybody) who could abuse those people resident in the home, the many acts of omission and commission that would constitute such an abuse, and the procedures, that have been agreed locally between all relevant parties, that should be followed when an abuse is suspected. In addition she demonstrated a deep determination to ensure that nobody in the home was ever put at risk of abuse, and a belief that none of her colleagues would tolerate anything being done to any of the people who use this service, that was contrary to their own wishes. 4 West Street, DS0000029679.V339492.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, 26, 27, 28, and 30. The quality outcome for the people who use the service in this area is good. This judgment was reached using all the available evidence including a visit to the service. People who use the service was seen to be living in a homely, comfortable, and safe environment, with personal and communal space that met their needs and lifestyle, and helped to promote their independence. The environment was clean, hygienic, and well maintained. EVIDENCE: A cursory visual examination of the exterior of the home did not identify any matters causing concern, and the grounds and fabric all appeared to be in good order. At every place where there was a change of elevation on an access pathway, there were substantial and appropriate rails provided for people who use the service to hold on to as they climbed or descended the step. 4 West Street, DS0000029679.V339492.R01.S.doc Version 5.2 Page 19 The deputy manager stated that the maintenance of the lawns that make up the majority of the garden was contracting out to a grounds maintenance firm, and the result of their work observed on this day, was very tidy and satisfactory. One of the people who use the service took the inspector on a guided tour of his room and of the communal areas, and one of the other people in the home asked if a member of staff could show the inspector her room, as she was enjoying a session of one-to-one hand pampering, and didnt want to move until her nails dried. The bedrooms were well and appropriately furnished with good quality fixtures and fittings, and demonstrated the history and interests of the people who lived in them. Televisions and music centres complemented those in the communal areas, and examples of handy work undertaken at college or that day occupation classes rubbed shoulders with treasured photos of family, records of achievement [both academic and sporting], and memorabilia of a particular interest such as railways, or a popular entertainer. Communal areas were clean and well furnished and suitably constructed to allow wheelchair access where this ever to be necessary, and the deputy manager listed the various items that are due for imminent renewal, though this was not always immediately apparent as being necessary, and demonstrated the commitment of the providers to maintain a high standard of furnishings, fixtures, and fittings, throughout their establishments. There was a separate laundry of the that was tidy and well equipped, and bathing facilities included both an assisted bath, and a shower room of the Falls and Gully type, and both had appropriately placed grab rails to provide assistance for use of the toilet. It was pleasing to see that since the last inspection cosmetic items such as pictures and new curtains had been added to the bathroom so that the experience for the people who use the service would be much more homely. 4 West Street, DS0000029679.V339492.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): 32, 34, and 35. The quality outcome for this group of people who use the service is good. This judgment was made using all available evidence including a visit to the service. The people who use the service were seen to be cared for by an adequate number of staff, who had received sufficient and appropriate training, and had been subject to a recruitment process and policies and procedures aimed at ensuring the safety and well-being of those people who lived in the home. EVIDENCE: Undertaking care duties in the home on the day of the inspection were: Deputy manager 7:30 a.m. to 5:00 p.m. One support worker 7:30 a.m. to 5:00 p.m. One support worker 7:30 a.m. to 3:00 p.m. One support worker 3:00 p.m. to 8:00 p.m. One support worker 3:00 p.m. to 11:00 p.m. watchful waking, and then on sleep in duty until 7:30 a.m. next morning. 4 West Street, DS0000029679.V339492.R01.S.doc Version 5.2 Page 21 One support (care) worker was engaged in a formal interview during which she demonstrated skills and knowledge about the people who use this service that would ensure their assessed needs and choices would be met in a way that was most acceptable to them. She confirmed that she had achieved NVQ level 2, and had received both induction training at the time she commenced her employment, and regular refresher training in all mandatory subjects since then, as well as in areas particularly associated with the conditions experienced by the people who use this service. During the course of the inspection observation of the dynamic between people who use the service and carers/support workers was observed to be sensitive, and to preserve their dignity, privacy, and independence at all times, including redirecting language or behaviour that would otherwise cause the individual to become stigmatised if they were to repeat it outside the home. During the formal interview with a member of staff, the details that have been observed recorded in her personal records concerning the process of employment were confirmed, inasmuch as the people who use the service had been protected by the provider requiring her to fill in a proper application form, get two written references, and a clear CRB and POVA first check, before allowing her to start work in the home. 4 West Street, DS0000029679.V339492.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): 37, 39, and 42. The quality outcomes for this group of people who use the service is good. This judgment was made using all the available evidence including a visit to the service. The people who use the service benefited from a well-run home, and were involved in the process of monitoring service, and not seem to be subject to any practices or environmental hazards that would affect their health, safety, and welfare. EVIDENCE: It was a recommendation of the previous report that arrangement should be made as soon as possible to appoint a new manager. During the interim the providers kept CSCI informed at all times of the steps they were taking to ensure good management of the home, and a new manager has now been appointed, though as of this time, she has not been registered by CSCI as a fit person, and is awaiting arrangements for an interview to confirm this. 4 West Street, DS0000029679.V339492.R01.S.doc Version 5.2 Page 23 The inspector was able to observe the views of people who use the service being canvassed during the afternoon of the inspection in relation to the things that they wanted to do. He was also able to discuss the group, set up by the providers, to engage people who live in the homes in the process of monitoring and reviewing what happens in the home including any proposed developments. During the tour of the environment both internally and externally nothing was seen to raise concerns about the health, safety, or welfare of the people who use this service, and in examining their personal care plans, confirmation was made of the risk assessments that had been undertaken both in relation to their individual condition and status, and also to their engagement with the environment. Reference was made during the last inspection to the state of the garage, and this has now been completely cleared of extraneous items, though as yet no action has been taken to divide the space so that the ignition source represented by the heating system in the room is isolated from the rest of the area. During this inspection period the commission was informed of concerns regarding a hole that had appeared in the garden, and the deputy manager was able to give up-to-date information about this, as the representatives of the National coal board had advised that it was not as a result of any mining activities, and was probably caused by a mixture of normal land settlement and the spell of extremely dry weather being experienced at that time. The hole has now been filled and that part of the garden replanted, for the continued enjoyment of the people who use the service. 4 West Street, DS0000029679.V339492.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 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 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 x 3 X 3 X X 3 X 4 West Street, DS0000029679.V339492.R01.S.doc Version 5.2 Page 25 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 4 West Street, DS0000029679.V339492.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor, Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ 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 4 West Street, DS0000029679.V339492.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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