Inspection on 16/04/07 for 76 Canute Road

This inspection was carried out on 16th April 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

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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 76 Canute Road Ore Hastings East Sussex TN35 5HT Lead Inspector Caroline Johnson Key Unannounced Inspection 16th April 2007 09:50 76 Canute Road DS0000068361.V333684.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 76 Canute Road DS0000068361.V333684.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. 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 76 Canute Road Address Ore Hastings East Sussex TN35 5HT 01424 457761 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) fionamacartney@tiscali.co.uk A S D Unique Services Limited Miss Fiona Macartney Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is six (6). Service users must be aged between eighteen (18) and sixty-five (65) years on admission. Service users with a learning disability only to be accommodated. Date of last inspection Brief Description of the Service: 76 Canute Road is situated in a residential area in Hastings. The home is registered to accommodate six adults with learning disabilities. The property is a two-storey building with one bedroom on the ground floor and five bedrooms on the first floor. Two of the bedrooms have ensuite bathroom facilities. The home is close to shops and amenities and there is easy access to Hastings. 76 Canute Road is one of four homes owned by the proprietors Mr and Mrs Kennard. The current scale of charges for the service range from £1,350 to £2,700 each week. Additional charges are made for hairdressing, chiropody, toiletries and sweets. Inspection reports are made available at the home and reference to the availability of reports is also included in the home’s statement of purpose. 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection carried out since the home was registered in November 2006. The home is registered to accommodate six adults with learning disabilities. At the time of inspection there were two residents accommodated. As part of this inspection process a site visit was carried out on 16 April 2007 and the visit lasted from 09.50am until 5.50pm. During the inspection time was spent with the manager and three staff members were interviewed in private. Both of the residents accommodated have complex needs, which include difficulties with communication. However, it was possible to observe staff working with the residents. A wide range of documentation was examined including pre admission documentation for one prospective resident and an examination of one care plan. In addition records held by the home in relation to staff training, recruitment, menus, health and safety, quality assurance, staff meeting minutes and resident consultation meetings were examined. As part of the inspection process comment cards were sent to the home for distribution to relatives and visiting professionals. Only one comment card was returned from a visiting professional and this was wholly positive. One of the comments was ‘residents are happy and well cared for’. What the service does well: The residents are settling in well to their home. The house is spacious ensuring that the residents have opportunities to spend time together and apart. The residents appeared to be content in their surroundings. There are very good training opportunities available for staff and staff value this. At least half of the staff team have completed NVQ to level two or above. Staff advised that they are ‘well supported’ and one staff member stated that the company is ‘the best I have ever worked for’. The home has introduced a number of audits to help them to assess and evaluate the quality of the care provided in the home. Staff observed during the course of their duties were respectful to the residents, communication was clear and staff were consistent in their approach to managing issues that arose during the day. Staff are gradually introducing new activities for the residents to try out and it is hoped that this area can be developed further as the residents settle into their home. Staff meetings are held regularly and as well as giving staff the opportunity to raise issues they also assist in providing clear communication to everyone about what is expected of them. Resident consultation meetings have been introduced and although to date success has been limited the intention is to continually review and adapt the approach used until the residents are able to participate more fully in this process. 76 Canute Road DS0000068361.V333684.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. 76 Canute Road DS0000068361.V333684.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 76 Canute Road DS0000068361.V333684.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives are given detailed information to assist them in making a decision about accommodation. EVIDENCE: There is a detailed statement of purpose in place and the service user guide has been prepared in a widget format. Pre admission documentation was seen in relation to one prospective resident. There was a detailed social care assessment in place and the owner had also carried out a detailed assessment of the individual’s needs and abilities. The manager advised that the prospective resident and their family had visited the home the previous week, another visit had been planned along with a transition meeting to discuss the plans for further preparation and moving into the home. A staff member spoken with stated that she would have responsibility for ensuring that the resident is registered with a local gp and would set up regular appointments for chiropody and opticians. She also said that one of the resident’s hobbies is cycling and there had already been a discussion about purchasing a staff bicycle so that this hobby could continue. 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 9 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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The care planning system is sufficiently detailed to ensure that staff have the information they require to meet the needs of the residents accommodated. The home is committed to improving the quality of their recording even further to demonstrate the extensive work they carry out in assisting residents to achieve their goals. EVIDENCE: Both of the residents have an IPP (individual programme plan) in place. The files contain detailed information, which has been under continual review as the needs of the residents have changed and as staff have become more familiar with the residents. Advice for staff on the action to be taken to meet individual residents needs is also detailed. Risk assessments are carried where there is a perceived risk and the assessments seen included detailed advice for staff to follow to minimise the risk of accidents/incidents occurring. In relation to one resident it was noted that use of the local community had temporarily been restricted due to concerns about safety for this individual and members of the public. However, there was a detailed risk assessment in place, which had been agreed with the individual’s social worker. 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 10 It was noted in one file that following a recent review a number of goals were set. The daily records refer to the goals set on each given day. If work has been carried out in relation to a goal this is either ticked or a cross is indicated. Sometimes when a cross is marked there is an explanation as to why an activity or goal did not happen, for example if there was no driver on duty, but often the reason is not explained. It is not possible to determine from the daily records the level of progress being made with each goal. However, the records are used well in relation to recording information about each of the resident’s emotional, social and physical needs. The manager advised that once the residents have lived in the home for six months they would carry out an autism specific assessment. Staff spoken with during the inspection were clear about the needs of the residents and one staff member who is new to the home stated that they were ‘impressed by the professionalism shown by staff’ and that ‘residents are given clear boundaries and the staff team are consistent in their approach to the residents’. Staff have recently had training on the use of TEACHH methods, which is a system, designed to aid communication. They are now beginning to introduce symbols, which will be used along with the spoken word to communicate and assist residents in making choices and decisions. When one of the residents was asked if he would like a cup of tea, he walked over to the counter in the kitchen and took up the coffee indicating that this was his preference. Service user consultation meetings are being held weekly. As part of this process there is a list of questions that have been devised and symbols are used to seek the views of the residents. Success to date has been limited but it is recognised that it is still early days and the staff will continue to evaluate progress made and how best to seek the views of the residents. 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. It is recognised that the service is new and that the residents have very complex needs. Taking this into consideration the home has made very good progress in enabling the residents to have opportunities to experience and participate in a range of interesting and stimulating activities. EVIDENCE: As the two residents are still settling into their new home a variety of activities have been tried and tested and the home are gradually building up a list of likes and dislikes. At the time of inspection programmes included, bowling, swimming and horse riding. On the day of inspection one resident’s activities included baking, a trip to a local shop and bowling. As there are currently only two residents it is very easy to organise activities that they can participate in together and apart. One resident has a car via their motability allowance. This resident enjoys spending time in quiet areas, so regular trips are arranged to country areas that involve walking and the residents have been able to make use of the 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 12 recent hot weather to enjoy picnics. One of the residents is funded to receive one to one staffing in the home and generally there is two to one staffing for community-based activities. One resident sees their mum at least two to three times a week. He enjoys bus rides and this is incorporated into his daily routine. He also enjoys Abba music and it was reported that he was supported to attend an Abba concert at the local theatre, which was very successful. Both residents were also taken to the Sealife centre and they enjoyed this trip. Staff spoken with stated that they are enjoying planning new activities and now that the weather is getting better the range of activities should increase. Where possible residents are encouraged to participate in household tasks. They assist with hovering their bedrooms and one resident is able to participate in doing his laundry, the other resident observes the task being carried out. A list of house rules have been drawn up so that residents are clear about what is expected of them. One of the residents does not like noise so the house rules ensure that this is respected. There is a four-week menu in place, which is varied and well balanced. Records show that alternatives are served occasionally to adapt to the individual wishes of the residents. The home has a healthy eating policy and there was evidence that there is a variety of fruit and vegetables served on a daily basis. The residents enjoy a take-away meal one evening a week. 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The systems in place for the management of medication and for ensuring that residents receive appropriate healthcare appointments mean that the residents’ health and welfare is continually monitored and reviewed. EVIDENCE: Since the home opened staff have supported both residents to attend a wide range of healthcare appointments. Due to the complex needs of the residents some of these visits were at their home. Arrangements have been made for a chiropodist to visit regularly. A dentist has also visited the home. Arrangements have also been made for an optician to visit. Referrals were also made to a psychologist for both men and to a psychiatrist and a speech therapist for one resident. Arrangements in place for the management of medication were examined and were in order. It is possible to carry out a clear Audit of medication from the time it is received into the home. Records of medication administered to residents were up to date and medication was stored appropriately. It was noted that there was a drug error on one occasion. The home took appropriate advice from their GP and the issue was raised with the staff member 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 14 concerned. On this occasion the Commission were not informed of the incident. The home has an administration of medications procedure in place. There is also a detailed risk assessment in place along with a drug identification checklist detailing medications used in the home, their dose and any potential side effects. The home also has a homely remedies list and guidelines. One of the residents has their medication in liquid form mixed with milk. This has been agreed with the resident’s gp. Unused medication is returned to the pharmacy on a regular basis. A number of staff have received training on medication with the local pharmacist and it was reported that a further course has been booked. All new staff also have to complete an in-house exam prior to being assessed as competent to administer medication. It was reported that some of the staff have been booked on a foundation in intermediate medication course. Staff seen in the course of their duties were observed treating residents with respect and dignity. It was noted that one resident has been able to make a choice about which care staff attend to his personal care needs, and the staff team respects this. All of the staff team have completed training on epilepsy and rectal diazepam. There are clear guidelines in place in relation to the management of epilepsy and when medication should be administered. The protocol for what to do if there is agency staff on duty that have not received the appropriate training is also clear. Prior to the inspection comment cards were sent to the home for distribution to relatives and visiting professionals. A positive response was received from a professional and one of the comments made included ‘residents are happy and well cared for’. 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The various systems in place to enable anyone wishing to make a complaint to do so. The procedures in place for the management of the residents’ complex and sometimes unpredictable challenging behaviours ensure that situations rarely escalate and can be managed effectively. EVIDENCE: There is a detailed complaint procedure in place. This is included in the home’s statement of purpose and the complaint procedure is also in the staff handbook, visitors book and in the service user guide. The complaint procedure for residents is completed using a widget format. It was reported that there have been no complaints since the home opened. No complaints have been made to the Commission about the service. The manager advised that she has recently completed a course, which will enable her to train her staff team on the issue of adult protection. It is her intention to provide training for the whole team over two training dates in April 2007. Some of the staff team have already received training on the subject in previous employment. All of the staff team have received in-house training on how to complete an adult alert form. One staff member spoken with stated that she and two colleagues had recently attended a course on managing adult protection issues. Between the date of the home opening until 30/3/07 there had been at least 19 adult protection alerts. The home keeps detailed records of all alerts. Most of the alerts involved minor incidents and the home’s practice is to continually review or introduce new risk assessments following each alert. Both of the 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 16 residents accommodated have complex needs and it is thought that the incidents are a result of both men getting to know each other and the staff team. A staff member spoken with stated that there was ‘a lot of testing of boundaries in the early stages but with greater consistency from the staff team and with both men getting to know each other better, the frequency of incidents has reduced’. The home reports all alerts to Social Services and they are also copied to the Commission. It was agreed that where Social Services require the home to take any specific action, details of the action taken by the home would also be copied to the Commission. The action agreed with the home has already been implemented on a number of occasions prior to the draft report being published. 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The layout of the home ensures that residents have a spacious, well-decorated and homely environment enabling residents to have opportunities to spend time together and apart. EVIDENCE: There are six bedrooms, two of which have ensuite facilities. In addition there is a bathroom on the ground and first floor. Residents are being encouraged and supported to personalise their bedrooms. Communal areas include a large lounge and a large dining room. A second lounge is also going to be changed into a sensory area and the manager advised that they would be purchasing snozelen equipment for this area. There is a large well-kept garden to the rear of the property. There are plans to purchase a barbeque for use during the summer and a swing chair for one of the residents. There is a keypad lock on the front door. Each of the bedroom doors have a lock fitted should a resident choose and be assessed as capable of managing a key. A nurse call system is fitted in each room in the house. Residents choose to have their bedroom doors open at night so fire doors are connected to the 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 18 home’s fire alarm system and would shut automatically if the alarms were to sound. In relation to fire safety it was noted that regular testing of equipment is carried out. Arrangements have been put in place to have the fire system serviced regularly and a fire drill has been held. The home carries out a quarterly audit of the fire arrangements. The fire risk assessment could not be located but the manager was confident that one had been carried out and was probably at the head office. A cleaner is employed to work a few hours three days a week. All areas of the home that were seen were clean and fresh. 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Staff have regular opportunities to attend courses that provide them with the opportunities to update their knowledge and manage the complex needs of the residents accommodated. EVIDENCE: The owners have recently taken over responsibility for staff recruitment so until all checks have been obtained the staff file remains at head office. There is also a new recruitment policy in place. Records were seen in relation to two staff recruited to work in the home. One of the staff members has yet to start working in the home so references, CRB and details of their qualifications were still at the head office. In relation to the second staff member, there were three references, a detailed application form, CRB, details of induction having started, identification, several certificates and supervision records in place. In relation to one reference there was an issue raised that required further clarification. The manager agreed to check with the owner that this had been done. The manager advised that the home is in the process of changing their induction package so that it complies with the Common Induction Standards. All of the staff team are working their way through the current package and 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 20 are at different stages of completion. Four of the staff team have completed NVQ level two or above and another carer is currently studying for level three. All of the staff have completed training in fire safety and food hygiene. Some of the staff have attended training in moving and handling and first aid and arrangements have been made for the remainder of the staff team to receive training. A couple of the staff stated that they had recently received training in TEACHH methods, which is designed to aid communication. They both stated that the course was excellent. Some of the staff have also attended some autism specific courses and the manager advised that it is her intention to arrange further training on autism specific courses. Staff spoken with advised that they receive monthly supervision and this was evident in the staff file seen. Staff stated that the manager is ‘very supportive’ and one staff member stated that the company is ‘the best I have ever worked for’. 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The home has and is continuing to develop a range of systems that ensure that the home is managed effectively and that the health and welfare of the residents is maintained. EVIDENCE: The manager has completed NVQ level 4 in management. She has also completed a BTec National Diploma in Social Care and a modern apprenticeship in Health and Social Care. She is currently studying towards a Batchelor of Philosophy Degree in Adults with Autism with Birmingham University. In addition she possesses a number of other relevant qualifications, which equip and enable her to manager the home competently. Staff meetings are held at least monthly and staff spoken with stated that they find the meetings useful. Records show that staff take it in turn to chair and minute the meetings. Staff are encouraged to share their views and all 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 22 decisions reached are documented. In addition senior staff also have regular meetings and service user consultation meetings are held weekly. The home is now beginning to develop their quality assurance systems. They have designed satisfaction questionnaires for residents, relatives and staff. The residents’ questionnaire is designed in widget form. Responses from the questionnaire were positive but it was evident that the residents did not understand some of the questions. The manager advised that they would continually evaluate and amend the questionnaire until they are sure that the residents are able to contribute to the process. At the time of inspection one relative satisfaction questionnaire had been received and this was wholly positive. The responses form the staff questionnaire had been collated. The manager advised that they are introducing audits for monitoring the medication system in the home and also for monitoring progress with the care plans. The manager has also started to complete a self-analysis of progress in advance of the monthly-unannounced visits carried out by the provider. The managers from within the company meet on a monthly basis and as preparation for this each manager has to write a report on the running of their home. The home has recently reviewed and updated their policy and procedure manual. The manager advised that staff are expected to read through the manual as part of induction and that as a way of ensuring that each policy is kept up to date she would also be putting a different policy on the notice board each week that staff will be expected to read and sign. There are a few new policies yet to be introduced. There are a range of risk assessments in place in relation to health and safety. This includes an electrical wiring certificate and certificates to show that the equipment in the home is tested and serviced regularly. Weekly checks are carried out to monitor that the nurse call system is working and arrangements have been made to have the call system serviced regularly. COSHH assessments have also been carried out and a detailed risk assessment of the building has also been carried out. 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “ ” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 2 X 3 3 3 X X 3 3 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 24 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 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 76 Canute Road DS0000068361.V333684.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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