Inspection on 20/11/06 for 81-83 Crofters Close

This inspection was carried out on 20th November 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

81-83 Crofters Close 23/02/06

81-83 Crofters Close 18/10/05

81-83 Crofters Close 23/02/05

81-83 Crofters Close 14/06/04

81-83 Crofters Close 15/03/04

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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 Crofters Close, 81/83 81/83 Crofters Close Droitwich Worcs WR9 9HT Lead Inspector Dianne Thompson Unannounced Inspection 20th November 2006 10:00 Crofters Close, 81/83 DS0000037500.V320255.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 Crofters Close, 81/83 DS0000037500.V320255.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. Crofters Close, 81/83 DS0000037500.V320255.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Crofters Close, 81/83 Address 81/83 Crofters Close Droitwich Worcs WR9 9HT 01905 773993 01905 773993 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) www.worcestershire.gov.uk Worcestershire County Council Ms Valerie Goode Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Crofters Close, 81/83 DS0000037500.V320255.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The home is situated in a quiet cul-de-sac on a residential estate, approximately one and a half miles from Droitwich town centre. There are shops on the estate and a park nearby. Worcestershire County Council operates the home and the responsible individual is Stephen Chandler. Mrs Val Goode is the registered manager. The communal rooms and two single bedrooms are on the ground floor with four single bedrooms on the first floor. The home has a two-person passenger lift. The home provides permanent accommodation and personal care for a maximum of six, highly dependent adults with learning and physical disabilities. Some of the service users have lived in the home since they were children. The home has its own unmarked minibus. The aim of the service is to provide a caring and safe home ensuring the privacy, dignity and comfort of each service user. The current fee for the service range from £103.65 per week. Charges which are additional to the fee include: • • • • • Personal toiletries, clothing and electrical items (TV and music centre). Activities not covered by the allowance made by the provider Holidays Major extra outings Hairdressing Crofters Close, 81/83 DS0000037500.V320255.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that included an unannounced visit to Crofters Close. The registered manager, who is retiring in two weeks time, was not available, but the newly appointed manager was present for part of the visit. The main purpose of this inspection was to assess the service provided against key National Minimum Standards. Service user and staff records were examined, and a tour of the building was also carried out. Accumulated evidence from reports of monthly visits by the provider’s representative was used to inform this report. Time was spent with the new home manager, service users and staff on duty. What the service does well: Crofters Close is located in a residential area of Droitwich. The home adequately provides for people who have learning and physical disabilities. The home is spacious with sufficient bathrooms, toilets and specialist equipment to meet the needs of service users. Information about the services offered at the home is available to help service users to choose whether they would like to live at Crofters Close and whether the home will meet their needs. Service users receive help and encouragement to lead active and interesting lives and are supported to access facilities within the wider community. They are also supported to maintain links with their families and to develop friendships. Personal and healthcare needs are clearly identified in care plans. These plans provide information and make sure that care is provided consistently and in ways that service users prefer. Monthly key worker reports are completed to provide up to date information. This is an example of good practice. The home has a medication policy and procedure, which is followed to make sure that all medication is administered and stored safely for the protection of service users and staff. Service users are protected by the home’s complaints procedure that gives information about how to complain. Staff support service users to express their views and any concerns they may have. The home is kept clean to make sure that good hygiene and infection control is maintained for the benefit of service users. Crofters Close, 81/83 DS0000037500.V320255.R01.S.doc Version 5.2 Page 6 Suitable staffing levels are maintained and staff are trained to help them meet service users’ needs. The staff team understand their responsibilities and are committed to their role. They are well supported and work together to provide service users with consistent and good quality care. The home’s recruitment policy and practices make sure that suitable staff are employed and that all necessary checks are made to ensure the safety of all service users. The home is managed with an open and positive approach. Worcestershire County Council (WCC) monitors the home in various ways to ensure that the service continues to develop as service users want and that the home remains a safe place to live and work in. What has improved since the last inspection? What they could do better: Update the service user guide and statement of purpose to reflect the changes in management to the service and the home. Risk assessments should be reviewed as required to make sure they are kept up to date. A photograph for all service users should be kept on files for identity purposes. Menus should be reviewed and developed to improve the choice of food available. When changes to medication are made, the information sheets should be retyped to prevent mistakes where alterations become unclear. Administrator support should be considered for the home. The emergency contact details held on file need to be changed, as they are out of date. Crofters Close, 81/83 DS0000037500.V320255.R01.S.doc Version 5.2 Page 7 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. Crofters Close, 81/83 DS0000037500.V320255.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 Crofters Close, 81/83 DS0000037500.V320255.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, 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information is provided about the services offered at the home to help service users make an informed choice about whether they would like to stay at Crofters Close and whether the home will meet their needs. EVIDENCE: There have been changes to the service management and the management of the home since the previous inspection. Information about the home will therefore need to be updated following these changes. The newly appointed manager said that these would be updated. The revised copies will be accessible to all, including visitors to the home. All service users will receive copies of relevant information during their introduction to the home, and these will be offered in preferred formats, such as symbols and pictures. Copies of updated information about the home, including a Statement of Purpose and Service User Guide has been supplied to the Commission for Social Care Inspection (CSCI) following the inspection visit to the home. Admission procedures and assessment forms are evident for those service user files examined. An admissions policy and procedure is in place. An assessment completed for a service user who has moved into the home since the last inspection demonstrates that the home obtains information about prospective Crofters Close, 81/83 DS0000037500.V320255.R01.S.doc Version 5.2 Page 10 service users, their background, their needs, their likes and dislikes when they are referred for a placement. Information is gathered from a range of sources including other relevant professionals, visits to homes or schools, and discussions with family members. Crofters Close, 81/83 DS0000037500.V320255.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, 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care plans provide staff with relevant information about users assessed needs. They include risk assessments on how risks are to be reduced and independence promoted. Service users are enabled to make choices and decisions in their daily lives and routines. EVIDENCE: Service user care plans are detailed and informative and include risk assessments. Staff have information to make sure that all care is provided in a preferred and consistent way that encourages independence. The care plans also include information and guidelines from other professionals to provide support in communication, behaviour and eating and drinking. The home provides a good standard of care for all service users, which has developed through getting to know individuals and how to respond to their needs. It was not possible to communicate with the service users during the Crofters Close, 81/83 DS0000037500.V320255.R01.S.doc Version 5.2 Page 12 inspection visit, as communication is very limited. Staff said they would know if someone was unhappy or uncomfortable and how to respond. Time was spent observing interaction between staff and service users. Communication was relaxed and respectful, with a level of understanding that is evidently based on knowledge and experience between staff and service users. Files for two service users were examined. Case tracking provides a view of how the home responds to the diversity of needs and how this is being managed and supported. This is particularly evident where health needs and disability requires greater input and support from all staff within the home. There was a service user photograph missing on one of the files examined. The manager confirmed this would be rectified. Service user care plans are being developed to make them more accessible to service users, using pictures and symbols. Risk assessments are included with care plans, however some of those seen had not been reviewed as specified. There is evidence that care plans are reviewed regularly and include action plans with timescales to follow. One care plan review had taken place on the morning of the inspection visit. Parents had attended this review meeting. Each service user is allocated a key worker to oversee their care. Each key worker builds a closer relationship so they gain more understanding and knowledge of individual needs. Monthly key worker reports are completed to provide up to date information. This is an example of good practice. Crofters Close, 81/83 DS0000037500.V320255.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, 14, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users receive help and encouragement to take part in activities and are supported to access facilities within the wider community. The home offers a varied menu although this could be developed to promote a more balanced and healthy diet for the welfare of all service users. EVIDENCE: The home provides a wide range of activities for service users, both in-house and within the local community. All activities are organised to take into account the individual needs and preferences of all service users, seeking to ensure everyone has the opportunity to participate. Activities are recorded in individual care plans to provide a clear record of individuals’ lifestyles. External activities include shopping, Snoezelen, swimming at Pershore, Kingstone day centre, lunch out, skittles, day trips, College, ride in the bus, Crofters Close, 81/83 DS0000037500.V320255.R01.S.doc Version 5.2 Page 14 cafes, pubs, and music sessions a Newland Hurst. Service users went to Burnham on Sea for a holiday, where they stayed in a caravan. Activities within the home include watching TV and videos, listening to music, photo activities, and an activities box. The home has developed a small sensory room in one of the lounge areas. Service users are encouraged to be involved in daily routines such as being present during the cleaning of bedrooms although they may be unable to do the physical task. Recording of activities has improved since the previous inspection and provides an overview of the lifestyle that is provided for service users living in the home. Evidence was seen which demonstrates that regular contact with friends and family is supported. Advocacy support has been sought for one service user who does not have family support, and will be available if required. The menu indicates that a variety of foods are offered, however it was noted that macaroni cheese had been served twice in five days. Regular meals of hash, cauliflower cheese, sausages, fish pie, cottage pie and faggots are recorded on the menus. The home needs to develop a more varied menu and one that promotes a healthy diet to include fresh meat, fish, and vegetables. Fresh fruit should be readily available. Crofters Close, 81/83 DS0000037500.V320255.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. Personal and healthcare needs are identified in care plans. The plans provide information to give support for all service users in a way that they prefer. The home has a medication policy and procedure, which is followed to make sure that all medication is administered and stored safely for the protection of service users and staff. EVIDENCE: Service users’ care records and plans provide detailed information about their physical and mental health and the support needed from staff to maintain their good hygiene and health. The care plans sampled contain information about service users preferred personal care routines. Staff said they are able to communicate with service users verbally and, in certain cases, with the additional use of gestures, sign language, and using objects of reference. Staff on duty said that all personal care is given in private to promote dignity for all service users. Crofters Close, 81/83 DS0000037500.V320255.R01.S.doc Version 5.2 Page 16 The Worcestershire Health Action Plans are being used. A form in service users records provides information and changes to medication as they occur. These forms should be retyped to reduce the possibility of mistakes where alterations become unclear. There is evidence that epilepsy management plans have been completed with support from the consultant and the community nurse. Care needs to be taken to ensure that where an observation is recorded in relation to a health concern, that any action and monitoring that follows is fully recorded. Service users and the home are well supported by medical services, which includes GP’s, epilepsy consultant, psychiatrist, dentist, community learning disability team, occupational health, and dietician. The home has a medication policy and procedure in place. Medicines are suitably and safely stored and there is appropriate storage for controlled drugs, should they be required. Medication records were checked and all was satisfactory. Medication administration was observed during the inspection visit, and considered to be satisfactory. The manager confirmed that the organisations policies and procedures would be followed should any medication error occur. Additionally these would be reported to CSCI. Crofters Close, 81/83 DS0000037500.V320255.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 are protected by the home’s complaints procedure that is available, with appropriate information for staff provided. Staff support service users to express their views and any concerns they may have. EVIDENCE: The home has a complaints procedure. There had been no complaints about the service to the home or to CSCI since the previous inspection. The home has procedures in place for the protection of vulnerable adults. Worcestershire County Guidelines on abuse and a copy of the Department of Health ‘No Secrets’ guidelines are available in the office. Some staff have received training in protecting vulnerable adults and courses in supporting service users who may have challenging behaviour. However physical intervention is not used or needed. The home has a complex system for recording the service users’ monies, which is detailed and has been audited in the last year. Service users now have their own bank accounts but service users’ monies are still going through a joint residents’ account. Consideration could also be given to the service users retaining their monies in their bedrooms. Crofters Close, 81/83 DS0000037500.V320255.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, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Crofters Close provides accommodation for service users that meets their needs and offers a safe, spacious and comfortable home. The home is kept clean which ensures that good hygiene and infection control is maintained for the benefit of service users. EVIDENCE: Crofters Close is located in a residential area of Droitwich. The home has a separate kitchen, dining room and three lounge areas. One lounge area has been fitted with sensory equipment and is used as a quiet area. A tour of the home was completed which included one service user’s bedroom. It was evident during the tour that service users are encouraged and supported to choose colour schemes and décor for their bedrooms, as well as their furnishings. Crofters Close, 81/83 DS0000037500.V320255.R01.S.doc Version 5.2 Page 19 Specialist equipment is available as required. This includes a specialist bath, hoists and stimulatory equipment such as mobiles and rope lights. Consideration is now given to identifying one member of care staff on each shift to be responsible for the preparation meals and for protective clothing to be identified for staff working in the kitchen. This was observed during the inspection visit. There is a dishwasher that ensures kitchen hygiene is maintained. The home is clean and tidy. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. Communal bathrooms have paper towels and liquid soap available. The laundry room is suitably equipped. The home has separate staff bathing, toilet and hand washing facilities. Crofters Close, 81/83 DS0000037500.V320255.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, 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Suitable staffing levels are being maintained, and relevant training is being arranged for staff to help them meet service users’ needs. The staff team understand their responsibilities and are committed to their role. They are well supported and work together to provide service users with consistent and quality care. The home’s recruitment policy and practices make sure that suitable staff are employed and that all necessary checks are made to ensure the safety of all service users. EVIDENCE: The home has a stable and committed staff team who are experienced, trained and skilled to meet the individual needs of the service users whom they know well. The service however, would benefit from administrative support. There is an on going training programme for staff to attend courses in safe working practices and caring for service users with special needs. This Crofters Close, 81/83 DS0000037500.V320255.R01.S.doc Version 5.2 Page 21 includes all mandatory training such as infection control, moving and handling and food hygiene. WCC operates a full training programme and access to more specialist courses relevant to the home will be provided. Six of the ten staff has an NVQ in care, which is above the recommended average of 50 of staff having an NVQ in care. Other staff are undertaking an NVQ in care and new staff undertaking the Learning Disability Award Framework (LDAF) induction training. Staffing levels have been reviewed for the admission of a sixth service user. The manager confirmed that all prospective staff complete an appropriate application form and that references are obtained including one from their most recent employer. Copies of proof of identity and documentation for all candidates are taken at interview. An enhanced CRB/POVA (police) check is undertaken before their appointment is confirmed. All staff are required to work a six-month probationary period at the home. Staff meetings are held regularly. Staff spoken to confirmed that they felt supported and enjoy working at the home, having worked there some twelve or fifteen years. Crofters Close, 81/83 DS0000037500.V320255.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, 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is managed with an open and positive approach. Worcestershire County Council monitors the home in various ways to ensure that the service continues to develop as service users want and that the home remains a safe place to live and work in. EVIDENCE: The registered manager is due to retire at the end of November 2006. The new home manager has been in post for two months preparing to take on the management role with effect 1st December 2006. The new manager Simon Edwards has many years experience in residential care and completed his Registered Managers Award in October 2006. Mr Edwards says he operates an open door management style. He has undertaken Crofters Close, 81/83 DS0000037500.V320255.R01.S.doc Version 5.2 Page 23 a wide range of other training relevant to service users’ needs. It is evident he is knowledgeable about learning disabilities and the implications for service users themselves and their care. The manager is to submit his application for registration to CSCI. Management responsibilities in the home are shared with a deputy manager. They are involved in organising the running of the home, health & safety promotion, staff supervision and induction. Staff confirmed the manager is approachable. They say the staff team works closely together to make sure that service user needs are met. In respect of management support from the provider, Worcestershire County Council (WCC) has Training and Human Resource Officers who are available to advise and support the home. The provider’s monthly visits are one of the ways that WCC monitors the service and how the home is being run. These visits include interviews with staff and service users and an audit of relevant aspects of the service, including records, environment, complaints received, finance and safety. Any actions that may be needed to address shortfalls are specified. WCC has introduced a quality assurance programme to the service. The audit was due for completion by the end of November and WCC will compile the quality assurance report. A copy of the report should be sent to the Commission for Social Care Inspection on completion to meet the requirement of the previous inspection. There are systems in place to maintain the health and safety of service users and staff that includes risk assessments for safe working practices and the accident book. Water temperatures are regularly checked. Staff have received training in safe working practices. The majority of staff have undertaken first aid training. The fire precautions are being regularly checked and a fire risk assessment is in place. Fire training was completed in June 2006. The home’s emergency contact details however, need to be updated as they include personnel who no longer work for WCC. Copies of updated information has been supplied to CSCI following the inspection visit. Automatic door closures have been fitted to fire doors, and although not fully completed at the time of the inspection visit, the manager has since confirmed that the work has been completed. This meets the requirement of the previous inspection. Crofters Close, 81/83 DS0000037500.V320255.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 3 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Crofters Close, 81/83 DS0000037500.V320255.R01.S.doc Version 5.2 Page 25 Yes 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. 1. 2. Standard YA9 YA17 Regulation 13 16 (i) Requirement Timescale for action 31/01/07 3. YA39 24 Risk assessments must be reviewed regularly or as specified. The home must provide in 31/12/06 sufficient quantities, suitable, wholesome and nutritious food, which is varied and properly prepared. The registered person shall 31/01/07 supply to the Commission a report in respect of any review in respect of the quality of care at the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA33 Good Practice Recommendations Consideration should be given to the provision of administrative support. Crofters Close, 81/83 DS0000037500.V320255.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Crofters Close, 81/83 DS0000037500.V320255.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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