Inspection on 13/06/06 for Acorns

This inspection was carried out on 13th June 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 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

Acorns 13/10/09

Acorns 25/10/07

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Acorns Walton Heath Pound Hill Crawley West Sussex RH10 3UE Lead Inspector Mrs M McCourt Unannounced Inspection 13th June 2006 10:00 Acorns DS0000066069.V291007.R01.S.doc Version 5.1 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 Acorns DS0000066069.V291007.R01.S.doc Version 5.1 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. Acorns DS0000066069.V291007.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Acorns Address Walton Heath Pound Hill Crawley West Sussex RH10 3UE 01202 706160 01202 706160 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) Evesleigh Care Homes Limited Mrs Mandy Jane Retter Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Acorns DS0000066069.V291007.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New registration Brief Description of the Service: Acorns is a care home registered to accommodate up to four Service Users with learning disabilities. The Registered Provider is Evesleigh Care Homes Ltd and the Registered Manager is Ms Mandy Retter. The current scale of monthly charges ranges from £1,581.28 to £1,606.28. This information was provided by the Registered Manager. Additional charges are made for personal items, such as; clothing, magazines, hairdressing, chiropody and so on. The home is a detached property, situated in a small cul-de-sac on the outskirts of Crawley town. There is easy access to all community facilities, including local rail and bus stations. Accommodation is provided over two floors. Each resident has their own en suite bedroom, located on the first floor. On the ground floor there is a comfortable living room with a large T.V., a quiet lounge, a good size kitchen, a utility room, a dining room, an office and a staff toilet. The garden is accessed via the kitchen door at the rear of the property. There is a large balcony area that has been made from decking, and from this, steps leading to a small, enclosed garden. The Service Users Guide and Statement of Purpose, which incorporates inspection reports, are both located in the entrance hall, at the home and are accessible to Service Users, staff, relatives and anyone else interested in the service. Acorns DS0000066069.V291007.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection was undertaken by one Inspector on Tuesday 13th June 2006 and lasted a total of eleven hours. Pre-inspection planning took approximately two days. A full tour of the building took place and included the observation of Health and Safety matters, hygiene issues, decorative order and a general overview of the atmosphere created within the home. Three staff members, the Registered Manager, a Senior Community Nurse and a Care Manager were spoken to at the time of inspection. Case tracking was carried out by examination of relevant records and information held on the staff and residents. The Inspector also spoke with both of the Service Users accommodated at the home. Policies and procedures were examined during the site visit. What the service does well: The home ensures monthly reviews are held for Service Users and these were found to be comprehensive and up to date. Staff support Service Users to access a range of activities, both in the community and in the home, empowering them to maintain skills in daily living. This was observed on several occasions throughout the course of the site visit. The home is in an excellent state of decoration and is beautifully kept. There is plenty of communal space, with Service Users having the choice of several different areas to relax in. In the hallway the inspector found a Service Users information file that includes policies and procedures on complaints, an example of a contract, past inspection reports, Statement of Purpose, Service Users Guide and information on current issues, i.e. leaflets giving practical advice about heatwaves. In addition the file holds copies of the local council newsletter. The file provided good all round information for interested parties. A staff information file contains an introduction to learning disabilities, and includes written information on a range of topics. This was considered by the Inspector as a good example of information for new staff. Acorns DS0000066069.V291007.R01.S.doc Version 5.1 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. Acorns DS0000066069.V291007.R01.S.doc Version 5.1 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 Acorns DS0000066069.V291007.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5 The outcome for Service Users was found to be good. Service Users are consulted about where they choose to live and are able to visit the home prior to moving in. Individual Service Users have a written contract with the home. EVIDENCE: The home has an Admissions/Referral Procedure and a Trial Visits Policy in place. The procedure states the process to be followed when considering a Service User’s placement, and includes; tea visits, overnight and weekend stays, followed by reviews to confirm the appropriateness of the placement. Discussion with the Registered Manager confirmed that thorough processes are in place regarding admission to the home. There are currently two vacancies, with some interest from prospective Service Users. Initial visits have been made and the Registered Manager said that tea visits, overnight and weekend stays will be offered as part of the progression. It is of particular importance that prospective Service Users are carefully placed in order to fit in with the complex needs of one of the Service Users already living at the home. The home’s Statement of Purpose and Service Users Guide are available to Service Users, relatives and any other interested parties. Personal files Acorns DS0000066069.V291007.R01.S.doc Version 5.1 Page 9 contained contracts of care, although one had not yet been signed by the manager. This was signed in the presence of the Inspector. Acorns DS0000066069.V291007.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. The outcome for Service Users was found to be good. Service Users are supported to take responsible risks as part of an independent lifestyle, but risk assessments need to be reviewed on a regular basis. Although Service Users are supported to make decisions, individual rights do not appear to be respected. EVIDENCE: The Inspector examined personal files for Service Users. Each file contained a contract of care, financial information, a personal profile, medical notes, dental records, psychiatric/psychology reports, health assessments, Statement of Purpose and a Service Users Guide, behaviour charts, sleep charts, weight charts, and so on. Acorns DS0000066069.V291007.R01.S.doc Version 5.1 Page 11 Monthly reports are comprehensive and review various subjects, such as; medication, outcomes from health appointments, behaviour and activities. They have been consistently completed for every single month, back to January 2006. A review report looked at by the Inspector was attended by the Registered Manager, Care Manager, Service Manager, relatives and a friend. Records show that review meetings are held every six months Goal planning takes place and deals with; the value of money, reading, writing and spelling, although some of the plans were in need of review. Risk assessments are in place and deal with a range of issues. Most of those seen were overdue their review date or had not been given a review date. A missing persons sheet details important information about the individual should they go missing from the home. The Inspector asked the Registered Manager if details of advocacy groups were available and was told that whilst individual Service Users do not have an assigned advocate, the home does have contact details for a local advocacy group. The Inspector was of the opinion that Service Users living at the home may benefit from this service. Service Users spoken with were able to confirm that choice is offered to them regarding daily life activities, such as; eating, going out, and so on. Acorns DS0000066069.V291007.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. The outcome for Service Users was found to be adequate. Service Users are able to take part in appropriate activities and are encouraged to access their local community. Although meals are not as healthy as they could be, staff are working with Service Users to change their eating habits. The Inspector was of the opinion that Service Users rights are not as respected as they should be. EVIDENCE: Personal files show how Service Users are assisted to access the local community and take part in relevant activities. Personal likes and dislikes are recorded and goal planning works towards specific achievements for individuals. Acorns DS0000066069.V291007.R01.S.doc Version 5.1 Page 13 During the inspection, one of the Service Users returned from attending a workshop programme and told the Inspector that she had been knitting, which she enjoys very much. Service Users are encouraged to pursue individual interests and hobbies, and within the home they are able to choose from watching T.V., listening to music, reading and so on. On the day of inspection one Service User was supported to go shopping with the community nurse who comes to assist with her care. Later in the day the Inspector observed both Service Users cleaning their rooms with dusters and polish, supported by staff. One of the Service Users told the Inspector that she like to do this. Service Users were also observed ironing and carrying out personal laundry duties. A timetable is on display for both Service Users and details their various activities throughout the week, including; college, household chores and personal interests. The Inspector noted that although both Service Users are on a healthy eating diet, their menus are not particularly healthy, and include meals such as; quiche, burgers, pizza, fish and chips and so on. The Registered Manager said that this was an on-going problem and that staff are working hard to change their eating habits, whilst promoting personal skills. Whilst at the home, the Inspector observed both Service Users cooking their own meal independently from each other. Annual holidays are enjoyed by both Service Users. One Service User went to a Butlins resort whilst the other travelled to Bude in Cornwall last year. This year, holidays are in the process of being planned. During examination of Service Users meeting minutes, the Inspector noted that these often referred to the Service Users as the girls. Staff were also observed to use the term girls throughout the inspection. In addition, some comments detailed in minutes are demeaning, and do not appear to respect the rights of the Service Users, making reference to behaviour whilst in the community, how they should dress, how they should sit at the dinner table, table manners and so on. There is a also reference to Service Users overhearing staff handovers, which in the Inspector’s opinion had not been dealt with appropriately, with the ‘blame’ apparently lying with the service user. The Inspector spoke with the Registered Manager about these issues and stressed the importance of not calling Service Users by names not agreed by Acorns DS0000066069.V291007.R01.S.doc Version 5.1 Page 14 them. Staff should understand that when speaking about Service Users in this way it represents an image and undermines the rights of people with a disability. It detracts from individuality. Furthermore, staff must remember that it is the Service Users home and should be treated as such. The Inspector was concerned that conversations are taking place within earshot of Service Users, and even if they listen in as was suggested, staff should not be discussing anything that they wouldnt say to that person. If it is of a personal nature, then an alternative way of passing this information should be sought. At a residents meeting recently, Service Users requested board games and activities, however there was no follow up at the next meeting and therefore no way of knowing if this was agreed. Service Users also asked why they are not allowed to keep pets. Overall the minutes gave the Inspector a sense of a them and us atmosphere within the home, and this should be addressed as soon as possible. Acorns DS0000066069.V291007.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. The outcome for Service Users was found to be good. The home provides Service Users with both physical and emotional support, with assistance from other health professionals if necessary. Policies and procedures are in place to ensure the correct administration of medication. EVIDENCE: Personal profiles are in place for Service Users, and these underpin the level of care provided by the home. Medical notes, dental records, psychiatric/psychology reports, health assessments, and so on are used to record pertinent health issues. Staff monitor specific health matters using behaviour charts, sleep charts, weight charts, and so on. Monthly reports are comprehensive and review overall health needs. Those looked at were up to date. Acorns DS0000066069.V291007.R01.S.doc Version 5.1 Page 16 The Inspector met and spoke with a Senior Community Nurse from the Martyn Long Centre. She visits the home on a regular basis to offer extra support to one of the Service Users living there. She told the Inspector that she was happy with the level of care offered to Service Users, and that they always seem well looked after. When asked if there was anything the home could improve on, the Inspector was told that training for staff around mental health needs would be beneficial, and that this matter had already been raised with the Registered Manager, who is trying to address it. The Inspector examined medication administration and storage. Medication is appropriately stored in a fixed metal cabinet. There were no signature gaps on MAR sheets and only some minor discrepancies with storage. Staff should remember to forward quantities of stock on to new MAR sheets in order to keep track of running totals of medicines. A pharmacy review in October last year left two recommendations, both of which have now been addressed. The medication file itself was tidy and up-to-date. On the front of the file there is a helpful explanation of the MDS four-week cycle and what needs to be done when, and in which week. Acorns DS0000066069.V291007.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The outcome for Service Users was found to be good. Service Users are protected from abuse, neglect and self-harm by a well trained staff team EVIDENCE: The Commission has not received any complaints in respect of this service. The complaints policy and procedure were both available. Service Users spoken with confirmed that they would speak to the manager if they had any concerns or problems. On discussion with staff they were able to demonstrate their awareness of adult protection issues. A complaints book was available, there had been no complaints recorded since 19.9.05. The Inspector noted that there was no outcome section for those complaints previously logged, and therefore no way of knowing how the complaint had been dealt with and whether or not it had been substantiated. Training records looked at during the inspection demonstrated that staff do receive Adult Abuse training and are aware of how to recognise signs of abuse. A missing persons policy is in place with details of the individual concerned. Acorns DS0000066069.V291007.R01.S.doc Version 5.1 Page 18 Records examined during the inspection demonstrated that the majority of the staff team have received training in recognising signs of abuse and how to report it. Acorns DS0000066069.V291007.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28 and 30. The outcome for Service Users was found to be excellent. The home is clean, bright and in good decorative order throughout. Service Users live in a comfortable and safe environment. EVIDENCE: The Inspector conducted a tour of the home. The ground floor comprises of kitchen, utility, lounge with large T.V., quiet room with small T.V. and radio, dining room, office and downstairs toilet. On the first floor, all four bedrooms have en suite facilities. The home is in an excellent state of decoration and is beautifully kept. Bathrooms and toilets are very clean and tidy. In the hallway the inspector found a Service Users information file that includes policies and procedures on complaints, an example of a contract, past inspection reports, Statement of Purpose, Service Users Guide and information on current issues, ie. leaflets giving practical advice about the heat wave. In addition the file holds copies of local council newsletter. NVQ and training Acorns DS0000066069.V291007.R01.S.doc Version 5.1 Page 20 percentages were laminated and held within the file, these are now out of date and not relevant. Close to the file was a small notice explaining the new ownership of the company, and that they are in a process of changing all of their policies and procedures and documentation onto the appropriately headed paper. The garden is accessed via the kitchen at the rear of the property. Initially you walk onto a raised decking area where there are tables and chairs. There is also a garden area that is covered in bark for ease of maintenance. The garden is enclosed by high trees and on the day of inspection was well maintained and tidy. The only disappointment on the tour of the premises was finding that the stair carpet, that was threadbare on each step, has been coloured in with what looked like blue felt-tipped pen to try to make it blend in!! Acorns DS0000066069.V291007.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. The outcome for Service Users was found to be adequate. Staff are trained in mandatory skills, although thought should be given to providing staff with mental health training in order to support one of the Service Users accommodated at the home. Recruitment procedures were not adequate to protect Service Users from harm, but it is noted that in the past, recruitment was undertaken by people other than the Registered Manager. EVIDENCE: There are seven staff currently employed at the home. One has NVQ level 2 and one is working towards this. The percentage is less than 30 , not 67 as was stated on the laminated notices found in the hallway. A training matrix was seen on display in the office. Mandatory training includes; manual handling, fire safety, food hygiene, COSHH, Health and Safety, 1st Aid and adult protection. Specific training includes; physical intervention, medication training, epilepsy and challenging behaviour. The Inspector noted that currently there is no Acorns DS0000066069.V291007.R01.S.doc Version 5.1 Page 22 training on Mental Health available for staff. The Registered Manager told the Inspector that Nicholas Davis, Project Manager, is going to work with the team on raising their awareness around mental health issues. The Inspector was of the opinion that due to the complexities of the subject and the issues presented by the Service User group, the home should ensure training be provided by an appropriately qualified person. Staff spoken with confirmed that they have received training in the subjects recorded. Staff also confirmed that they received regular supervision and records looked at contained detailed supervision notes. Recruitment procedures were examined by the Inspector who looked at two files. Procedures had not been properly carried out, but on discussion with the Registered Manager, the Inspector was told that in the past, recruitment had been done by other managers, and not by herself. The new company has changed this so that managers now do all the recruitment themselves. Staff meeting minutes were looked at by the Inspector, and again, there is regular reference to “the girls”. Agenda items include topics such as; Service Users issues, training, health and safety, staff changes and so on. Acorns DS0000066069.V291007.R01.S.doc Version 5.1 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 and 43. The outcome for Service Users was found to be good. Service Users do benefit from a well run home, but the Registered Manager must ensure that their views underpin all self-monitoring and development of the home. Staff would benefit from equalities training. EVIDENCE: The Registered Manager’s name is Ms Mandy Retter, and she has managed the home for three years. She has four years experience of working with learning disabilities. Prior to this she worked with older people. She holds NVQ4 and her RMA. She is a manual handling trainer for the company and is also and NVQ assessor. Acorns DS0000066069.V291007.R01.S.doc Version 5.1 Page 24 A quality Assurance survey has just been conducted for Service Users, staff, care managers and next of kin. The results have been compiled and published for the conference held on 2nd May 2006. A copy of the report is has been received by the Inspector. There is no in-house survey or questionnaire available, and although Service Users meetings do take place, there is no follow-up format for requests made. Information on health & safety, 1st Aid appointed person, weekly safety checks for fire alarms, food hygiene, infection control, 1st Aid stock checks and water temperature checks are carried out and recorded. The COSHH cupboard, located on the ground floor, was locked. There is a simple and easy to follow colour code system for infection control purposes. Employers liability is in place. All policies and procedures are in place at the home, and a statement informing the reader that all policies and procedure are being adopted by the new company is in place. The company now employs a Central Policy and Procedure Review Forum that meets every four weeks to implement and/or revise where necessary. The fire log book was looked at and showed drills and equipment checks are up to date. These are carried out by a maintenance co-ordinator on a monthly basis. A fire risk assessment was completed in January 2006. Fire drills have been carried out regularly throughout the year, as is equipment testing. However, the fire service contract was only valid to March 2005 and needs to be renewed. The Inspector examined incident and accident reports. One particular incident involved a serious incident that should have been reported to the police. The Registered Manager agreed that this should have been reported, but a decision was taken not to as the Service User did not seem too upset. Health and safety risk assessments were in place, covering: staff cars, paper shredding, slipping on the decking area, wet floors, falling from the balcony, cooking, chemicals, hot water, the stair carpet (because it is thread bare), and so on. The Accident book had details of various accidents, although some of those reported had been inappropriately written up. Acorns DS0000066069.V291007.R01.S.doc Version 5.1 Page 25 A staff information file contains an introduction to learning disabilities, the common causes (genetic & environmental). Information on epilepsy, mental health, anger, person centred planning, human rights, ethnic minority religions and so on. This was considered by the Inspector as a good example of information for new staff. All policies and procedures have been reviewed in February 2006. Acorns DS0000066069.V291007.R01.S.doc Version 5.1 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 x 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 4 25 x 26 x 27 4 28 4 29 x 30 4 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 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 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x 3 3 3 Acorns DS0000066069.V291007.R01.S.doc Version 5.1 Page 27 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 Refer to Standard YA16 Good Practice Recommendations 16.5 – staff use Service Users’ preferred form of address, which is recorded in the individual Plan. 16.6 – staff talk to and interact with Service Users, not exclusively with each other. 16.8 - Service Users have unrestricted access to the home and grounds. 35.6 – A training needs assessment is carried out for the staff team as a whole, and an impact assessment of all staff development is undertaken to identify the benefits for Service Users and to inform future planning. 35.7 – Training and development are linked to the home’s service aims and to Service Users’ needs and individual Plans; and Service Users are involved in determining staff training needs and plans. 39 – Effective quality assurance and quality monitoring systems, based on seeking the views of Service Users are in place to measure success in achieving the aims, objectives and Statement of Purpose of the home. DS0000066069.V291007.R01.S.doc Version 5.1 Page 28 2 YA35 3 YA39 Acorns Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 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 Acorns DS0000066069.V291007.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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