Inspection on 05/11/07 for 42 Stadon Road

This inspection was carried out on 5th November 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

42 Stadon Road 27/11/06

42 Stadon Road 04/10/05

42 Stadon Road 10/05/05

42 Stadon Road 16/02/05

42 Stadon Road 05/05/04

Similar services:

St Marys Nursing Home

Thornham Grove

Chater Lodge

Conifer Lodge

Tixover Care Home

Toynton College (Cluster Five)

Egerton Lodge Care Home

Cedar Court Nursing and Residential Home

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

CARE HOME ADULTS 18-65 42 Stadon Road Anstey Leicestershire LE7 7AY Lead Inspector Diane Butler Unannounced Inspection 5 November 2007 08:30 th 42 Stadon Road DS0000001828.V351628.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 42 Stadon Road DS0000001828.V351628.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. 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 42 Stadon Road Address Anstey Leicestershire LE7 7AY 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) 0116 2352457 0116 2352763 shirley.harriman@lc-uk.org www.leonard-cheshire.org.uk Leonard Cheshire Ms Shirley Harriman Care Home 7 Category(ies) of Physical disability (6), Physical disability over 65 registration, with number years of age (1) of places 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 42 Stadon Road Care Home is registered to provide personal care to male and female service users who fall within the following categories Physical Disability (PD) 7 Physical Disability over the age of 65 years PD(E) 1 To accommodate the 2 named persons of category PD(E) identified in correspondence dated 25th October 2001 The maximum number of persons to be accommodated at 42 Stadon Road is 7 27th November 2006 2. 3. Date of last inspection Brief Description of the Service: 42 Stadon Road is a care home providing personal care and support for up to 7 service users with a physical disability. The home was purpose built in 2001 and is owned and managed by Leonard Cheshire Disability. The home is situated in Anstey, a village on the outskirts of Leicester and is within walking distance to the local amenities, including shops, library and the local social club. All the bedrooms are single and offer ensuite facilities, which include a toilet and shower area. There is a lounge, dining room and kitchen available and all the communal areas within the home provide space in which the service users can spend time together in comfort. There is a garden area for the service users and their visitors to enjoy, which includes a paved walk way and raised flowerbeds. The charges for living at the home vary depending on individuals assessed needs. Current charges range from £671.65 per week to £908.66 per week. Details of what is included in the charges can be found in the Service User Guide (a document which provides relevant information about the home), which is given to all service users on arrival at the home. A copy of the latest Inspection report is available at the home, or it can be accessed via the CSCI website: www.csci.org.uk. Further information about the home is available from the registered manager. 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit, which took place over a four and a half hour period on Monday 5th November 2007. The registered manager was on duty at the time of the inspection. When undertaking key inspections the Commission for Social Care Inspection (CSCI) focuses upon outcomes for service users and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting three service users and tracking the care they received through looking at their records, speaking with them and discussion with support workers on duty at the time of the visit. Observation was also used to evidence whether care needs were being met. A further two service users were spoken with during the visit Further planning for the site visit included checking the service history and last Inspection report and looking through the AQAA document (Annual Quality Assurance Assessment, which is sent to the CSCI by the provider and contains information about the service), which was submitted to the Commission for Social Care Inspection prior to the visit. Questionnaires were also sent to the service users, their relatives and care workers to gain their views of 42 Stadon Road. Comments received include: “I always make decisions for myself but understand that there is always support available here if and when needed”. “I love it at the Anstey home, the staff here are very good and I am very happy here”. “They help us meet our goals, aspirations and make such a difference to the quality of life we can achieve”. “Sometimes I would like to go out for a walk round the village, but we only have two staff on and they cannot leave the home”. “Could possibly do with more outings”. “All needs are met, we have no cause for concern”. “They provide a happy atmosphere”. 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Review both the care plan and risk assessment documentation more regularly. This would ensure that the support workers have up to date and relevant information to assist with the care and support of the service users. 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 7 Ensure that there is a consistency when recording the administration of items such as powders and creams and the use of incontinent sheaths. Support workers need to be completing the administration records in line with the organisation’s medication policy. Monitor current staffing levels to ensure appropriate numbers are on duty at all times to meet the personal, health and social needs of the service users in their care. 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. 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users needs are appropriately assessed before moving into the home to ensure that their care and support needs can be met. EVIDENCE: A Statement of Purpose is in place. This document, which was reviewed in September of this year, includes details of the services that can be provided and what training the staff have completed. A service user guide is also in place and a copy of this document is given to all service users when they arrive at the home. This document includes information on local amenities and the daily arrangements of the home. On speaking with three service users it was confirmed that they had received this information, which they keep in their rooms. The registered manager explained that an assessment of need is obtained for all prospective service users, this is looked at carefully to ensure that the staff working at the home can meet their identified needs. On checking the paperwork belonging to the one service user who has moved into the home since the last inspection in November last year it was noted that the appropriate assessment paperwork was in place. 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 10 All prospective service users are invited to look around the home and stay for a meal, this enables them to get a feel of the home and to decide whether it is the right place for them. Service users spoken with confirmed that they were able to visit before moving in and comments included in the questionnaires received also confirmed that they had had the opportunity to look around and when possible choose the room they wished to stay in. Comments received included: “I had a choice and chose Anstey”. “It was a new built home. I had a look around it looked lovely so I wanted to come here”. All service users have a statement of terms and conditions of residency. This document includes details of what services will be provided and is signed by both the resident and a representative of the home. 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are consulted on, and participate in, all aspects of the home. EVIDENCE: On checking the files belonging to three service users it was noted that all included a copy of their care plan. These plans covered the health, personal and social care needs of the service users and included their likes and dislikes within daily living. A quick reference care plan was also in place that gives the reader a quick snap shot of the help and support the service user requires. It was noted that although the care plans were in place not all had been reviewed on a regular basis, with one not being reviewed since April last year. This was discussed with the registered manager who stated that this would be addressed. 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 12 One service user spoken with during the visit explained that they didn’t wish to have a care plan and that they found this somewhat demeaning, as they were more than capable of articulating their needs. The registered manager has respected this wish and the service user discusses all aspects of their care and support needs with the support workers on a daily basis. All service users living in the home are able to make decisions on a daily basis, these include when to get up, what to wear, what to eat and where to eat it, and what activity they wish to complete in their free time. Evidence was seen throughout the inspection of the service users making there own decisions. This included one service user deciding to have a lay in and a second deciding what to have for lunch. Service users are fully involved in life at the home. Issues that arise are discussed on a daily basis and service user meetings are held on a regular basis. Minutes of the last meeting held in August 2007 were seen. The registered manager stated that whenever possible service users would be involved in the recruitment process for new support workers, this was confirmed whilst talking to one of the service users in the home at the time of the visit. Support workers enable the service users to take responsible risks on a daily basis and risk assessments are in place for all activities undertaken. It was noted that some of these risk assessments hadn’t been reviewed for some time, including one, which had last been reviewed in April 2006. This was discussed with the registered manager who stated that this would be addressed. Service users are enabled to live an independent life style within the home and support workers support the service users to meet their individual goals. Comments received included: “Staff are excellent and treat each one of us as an individual”. “The staff let me do as much as I can for myself”. “I go to a day centre three days, I don’t have to go if I don’t want, I can do whatever I want to”. 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Daily routines within the home promote service users independence and individual choices. EVIDENCE: Six of the seven service users currently living in the home are supported to access local colleges and day centres, the remaining service user chooses not to, but chooses to help out around the home including helping with the preparation of vegetables for their evening meal etc. One service user works at a local school each week and support workers enable those service users who wish to, to access their preferred places of worship. 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 14 Evidence was seen to confirm that service users are supported to access appropriate community and leisure activities, this included supporting service users on shopping trips, attending the local library and visiting the local social club for a drink. One service users explained, “xxx [the support worker] sorts out shopping trips and appointments”. On discussion with the registered manager it was evident that she had identified a need for more one to one support for one of the service users in her care. We were informed that she was currently looking into ways to provide this extra support. Daily routines within the home promote privacy, independence and choice. Service users can choose whether to be alone or join the other service users. They are encouraged and supported to do their own laundry and support workers ensure privacy by knocking on doors and waiting to be invited in. Comments received included: “I ask when I want to go to bed, and I can stay in bed if I want”. “They wash it [the service users laundry], iron it and I collect it (when I remember). “They have got to know me as a person”. “I help in the kitchen, I’m going to do the onions for tea”. A healthy balanced diet is offered, choices are provided at every mealtime and the service users are supported to plan their own meals on a weekly basis. Mealtimes are relaxed, flexible and unrushed. Comments received included: “The food is good and we are all involved in sorting the menus”. “If I don’t like something they will get me something else”. 42 Stadon Road DS0000001828.V351628.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): 18,19,20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are looked after well in respect of their health and personal care. EVIDENCE: Service users are encouraged to be as independent as possible, for those less able to care for themselves, support and guidance is offered in a sensitive and flexible manner. Preferences regarding the delivery of care are included in the care plan documentation and all service users spoken with confirmed that they were treated with respect and care and support was provided in a dignified manner. Comments received included: “The staff are very nice, they treat me very well”. “I talk to the staff and they listen, I get all the help I need”. 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 16 On checking the records belonging to three service users it was evident that the registered manager and the support workers assist them to access healthcare services when needed. Services contacted on the service users behalf included GP’s, dentist, opticians and chiropodists. Medication records were checked. Medication had been appropriately signed into the home and medication had been signed for when given to the service user. It was noted that for items such as powders, creams and the use of incontinent sheaths etc, some support workers were signing to say these had been administered/used and others were not, showing an inconsistency in the recording. This was discussed with the registered manager who stated that this would be addressed immediately. There was no surplus of medication as noted at the previous inspection and all medication was stored appropriately and securely. 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users feel safe and protected from harm. EVIDENCE: A complaints procedure is in place and copies of this are displayed throughout the home. Details of how to make a complaint are also included in the service user guide, which is given to each service user on moving into the home. The AQAA (Annual Quality Assurance Assessment) document received prior to this visit stated that one complaint had been received since the last inspection in November last year. This was confirmed on checking the complaints file and on speaking with the registered manager. It was noted that this complaint, which concerned the care received by one of the service users, was appropriately investigated and suitable actions were taken to address the issue and to ensure that it didn’t happen again. All service users spoken with during the visit were aware of whom to speak to if they had any concerns and all were confident that any concern would be taken seriously and appropriately dealt with. Comments received included: “I would talk to Shirley [the registered manager] she would sort it”. 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 18 “Shirley is always available and will listen”. “I know there is a complaints procedure but if we can sort things out we will, I have used it in the past with satisfactory results”. All support workers attend training in the protection of vulnerable adults during their induction period and regular updates are also provided. The registered manager is aware of the procedures to follow to ensure that the service users in her care are protected and all support workers spoken with during the visit were aware of the actions to take, should they suspect any form of abuse. All service users spoken with said that they felt safe living in the home. 42 Stadon Road DS0000001828.V351628.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): 24,25,26,27,28,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The standard of accommodation within the home is good, providing the service users with a comfortable place to live. EVIDENCE: 42 Stadon Road is a purpose built care home providing accommodation for up to seven service users with a physical disability. The home is spacious and fully accessible for those using a wheelchair. All the bedrooms are single and offer ensuite facilities, which include a toilet and shower area. Communal facilities include a large lounge area, dining area and kitchen and assisted bathing facilities are available. The kitchen is equipped with adjustable tops and sink area, which enables the service users easier access. 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 20 There is a garden area for the service users and their visitors to enjoy, which includes a paved walk way and raised flowerbeds. All areas of the home seen on this occasion were appropriately maintained and suited to the service users needs. The decoration and furnishings throughout the home are of a good standard and are presented in a comfortable and homely way. The rooms belonging to four service users were seen during the visit. All were clean, appropriately furnished and included their own personal belongings. All service users spoken with were satisfied with the accommodation provided. 42 Stadon Road DS0000001828.V351628.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): 32,34,35,36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and qualified staff. EVIDENCE: 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 22 There are currently two support workers on anyone shift to care and support for the seven service users living at the home. On speaking with the support workers on duty during the visit both stated that this was normally sufficient, however as they are also responsible for the cooking and cleaning it can sometimes get a little hard to fit everything in. All service users spoken with felt there were adequate numbers of staff on duty to meet their needs. One service users explained, “The staff are excellent and treat each one of us as an individual”. A second added, “They are always there when you need them”. Comments included in questionnaires received included: “I think we have very good staff here but we need more as it can be very hard work with only two on at every shift. The staff here do all the cooking and cleaning, I think if we had help with that we could do more things with the clients”. “Higher staffing levels would give the staff more time to spend with the service users”. An appropriate recruitment procedure is in place, application forms are completed, references are collected and a CRB (Criminal Records Bureau) and POVA 1st (Protection of Vulnerable Adults) check are obtained. On checking the files belonging to the two support workers on duty during the visit all the necessary checks were found to be in place. The registered manager stated that the service users are involved in the recruitment of new support workers when ever possible. This was confirmed on speaking with one of the service users during the visit. A period of induction is provided to all new support workers, this involves spending one week learning about policies and procedures of the organisation and completing the relevant training and working through an Induction, learning and development pack. On checking the training records it was evident that relevant training had been provided and both support workers confirmed that training is always available. Training completed included: Disability and the Law Health and Safety Infection Control Food Hygiene 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 23 First Aid Moving and Handling Safe handling of medicines Protection of Vulnerable Adults. Both support workers on duty at the time of the visit had completed their NVQ (National Vocational Qualification) and on checking the AQAA document received prior to this visit it was noted that of the eleven support workers currently employed eight have completed an NVQ Qualification and two are currently working toward achieving this qualification. Staff meetings and supervision sessions are provided on a regular basis and both support workers spoken with during the visit stated that they felt supported by the registered manager. 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41,42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from the open and positive atmosphere, which is evident throughout the home. EVIDENCE: The registered manager has worked in the care profession for twelve years, seven of these with Leonard Cheshire and has recently completed her certificate in management. She currently works at the home for three days a week, with the remaining two days being spent supporting other Leonard Cheshire homes. On speaking with both the registered manager and the support workers on duty during the visit it was evident that this arrangement, which was agreed 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 25 by the Commission for Social Care Inspection was currently working with both support workers stating that they felt well supported and that the registered manager was at the end of the phone at all times. Service user meetings, which are run by a volunteer from the local community, are held on a regular basis enabling the service users to share their views on the service provided and annual quetionaires are also completed. The registered manager also meets with the service users on a one to one basis to ensure that they remain happy with the care and support that the support workers provide. Policies and procedures for the health, safety and welfare of the service users are in place and all support workers are made aware of these during the induction process. Risk assessments were in place for safe working practices, though it was noted that some had not been reviewed for over a year. The registered manager stated that this would be addressed. Service users have full access to their records with care plans being kept in their bedrooms. A key worker system is in place and it is the key workers responsibility to keep these records up to date with the involvement of the service users. One service user confirmed that this does take place though it was noted that not all care plans or weekly records were fully up to date. The registered manager stated that this would be addressed straight the way. It was evident during the visit that the service users benefit from the ethos, leadership and management that the registered manager provides. There was a relaxed and friendly atmosphere throughout the visit and the interactions between support workers and service users were positive, informal and inclusive. One service user explained, “This is a very professionally run home, I would recommend it to anyone”. 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 26 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 3 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 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 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 3 3 X 3 3 X 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 27 N0 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. 1. 2. 3 Refer to Standard YA6 YA9 YA20 Good Practice Recommendations The registered person should ensure that care plans are reviewed with service users, at least every six months. The registered person should ensure that any identified risks to the service users are reviewed on a regular basis. The registered person should ensure that there is consistency when recording the administration of items such as powders and creams and the use of incontinent sheaths. The registered person should monitor staffing levels to ensure that the ever changing needs of the service users continue to be met. 4 YA33 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 42 Stadon Road DS0000001828.V351628.R01.S.doc Version 5.2 Page 29 - 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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