Inspection on 09/10/08 for Alexandra House

This inspection was carried out on 9th October 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alexandra House 17/04/08

Alexandra House 26/09/06

Alexandra House 28/12/05

Alexandra House 14/06/05

Alexandra House 15/12/04

Alexandra House 22/07/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 19/03/2009.

CARE HOME ADULTS 18-65 Alexandra House Alexandra House 31 Pollards Oak Road Hurst Green Oxted Surrey RH8 0JL Lead Inspector Jo Griffiths Unannounced Inspection 9th October 2008 09:15 Alexandra House DS0000013549.V372739.R02.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 Alexandra House DS0000013549.V372739.R02.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. Alexandra House DS0000013549.V372739.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexandra House Address 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) Alexandra House 31 Pollards Oak Road Hurst Green Oxted Surrey RH8 0JL 01883 380739 Mrs Myrna Noorbaccus Mr Mike Noorbaccus Mrs Myrna Noorbaccus Mr Mike Noorbaccus Care Home 5 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (2) of places Alexandra House DS0000013549.V372739.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The number of persons for whom residential accommodation and personal care is provided at any one time shall not exceed FIVE (5). The age/age range of the persons to be accommodated will be: 3 PEOPLE UP TO 64 YEARS & 2 OVER 65 23rd June 2008 Date of last inspection Brief Description of the Service: Alexandra House is registered with the Commission for Social Care Inspection to provide accommodation and care to five adults with a learning disability. The property is located in a residential area in Oxted in Surrey and is close to public amenities. Accommodation is on two floors and comprises of a kitchen, dining room, lounge, laundry area, bathrooms, toilets, one shared bedroom with an en-suite bathroom and three single bedrooms. One bedroom and bathroom is on the ground floor and is accessible to wheelchair users. The home has a front and rear garden. Private parking is available. The range of fees charged by the home is £900 - £1700 per week, depending on an individual assessment of need. Alexandra House DS0000013549.V372739.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was a key inspection of the care home. At the last key inspection of the service, on 17th April 2008, a Statutory Requirement Notice was issued. A random inspection took place on 23rd June 2008 to check that the Notice had been complied with and that improvements had been made. It was found that the Notice had been complied with at this time. As part of this key inspection the inspector sent surveys to the four people who are currently using the service to gather their views. The Managers and staff helped people to complete these. The feedback was positive for all four people. A visit to the service took place on 9th October 2008 between 9.15am and 1.15pm. Two of the people that live in the home were spoken with briefly about their experiences in the home before they went out to their activities. Two staff members were spoken with and one of the Managers of the home was available throughout the inspection and gave feedback on the progress made since the last inspection. Some of the records and documents maintained for the running of the home were inspected. What the service does well: What has improved since the last inspection? Since the last key inspection there have been many improvements to the service. The Statement of Purpose and Service User Guide now provide people with all the information they need about the charges that will be made for the service and how to make a complaint about the service if they are not happy. All the people living in the home have had a review of their needs and their care plans have been updated. They are now able to access their care plans and have been involved in writing them. Since the last inspection the managers have ensured that all the staff that are employed in the home are able to communicate with the people that live there in their preferred language. This means that staff can better understand and meet peoples needs. Alexandra House DS0000013549.V372739.R02.S.doc Version 5.2 Page 6 People have more choices of their meals and are enjoying some new activities including courses at college. All the necessary checks are now being made when new staff are recruited, to safeguard the people in the home, and the managers are reviewing all the training needs of the staff. Training in person centred planning has been booked for staff so that they are able to help people to take control of their lives and make their own decisions. 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. Alexandra House DS0000013549.V372739.R02.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 Alexandra House DS0000013549.V372739.R02.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): Standards 1, 2 and 5 People that use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People looking to move to the home are provided with the information they need in order to make an informed decision about the service. Everyone moving to the home has an assessment of their needs to ensure their needs can be met before they move in. A contract and terms and conditions statement is issued to each individual as they move in. EVIDENCE: The Service User Guide and Statement of Purpose were seen. These had both been reviewed in May 2008 and now contained clear information about the fees charged for the service and any charges that are made in addition to the fees. Both documents contained a summary of the complaints procedure for the home. Currently the Service User Guide and Statement of Purpose are presented in written format. The Manager said that he would consider producing this in different formats for anyone new looking to move to the home. Everyone currently living in the home had an assessment of needs. This had been completed prior to them first moving to the home, but has been updated. Alexandra House DS0000013549.V372739.R02.S.doc Version 5.2 Page 9 The last update for all four people was in June 2008. The assessment also now takes account of mental capacity issues. Each person has a contract for their care. There is a contract between the home and the funding authority and a terms and conditions document between the individual and the home. Both were available on the individuals file. Alexandra House DS0000013549.V372739.R02.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 People that use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have a care plan that meets the majority of their assessed needs. Further development of the plans will benefit people in the home by ensuring their emotional needs are fully met. People are supported to make their own decisions in some areas of their life through person centred planning. People are supported to take reasonable risks as part of an independent lifestyle. EVIDENCE: At the last key inspection a Statutory Requirement Notice was issued that required that people living in the home be involved in drawing up their care plan to ensure it meets their individual needs. The Notice also required staff to Alexandra House DS0000013549.V372739.R02.S.doc Version 5.2 Page 11 be trained and competent to be able to understand and follow the plans. The Statutory Requirement Notice was found to have been met at the random inspection on 23rd June 2008. The care plans for two people were seen. These are no longer stored on the computer but are available to the individual to whom it relates and easily accessible for staff to follow. Both plans had been reviewed and amended in September 2008. Three of the four people living in the home had had a review with their Care Manager since the last key inspection. The care plan files contained an overall agreed care plan and specific guidance for staff on how to support people with various individual needs. Both the care plans included evidence of the use of person centred planning tools to help people make decisions about their daily lives. The Manager has booked training for staff in person centred planning, which is to take place on 21st October 2008. This will greatly benefit people in the home as the staff will have a better understanding of how to support people to take control of their own lives and make their own decisions. The care plans can then be further developed to ensure people make their own decisions about their current support and about their future hopes and aspirations. The wording used in the care plans has been changed since the last key inspection. It now reflects peoples needs in a more positive light. The care plans have vastly improved since the last key inspection and they are now presented in a user friendly way for the person, to help them understand their own plan. The Manager should continue to develop the care plans to ensure that all of an individuals needs are included in the plan. This should include peoples needs with regard to their sexuality and personal relationships. A policy document for staff on supporting individuals with their sexuality has been produced since the last inspection. This will aid staff in developing the plans further in this area. Risk assessments are in place, and have been reviewed recently, for all areas of individual risk. This includes bathing and use of the homes vehicle. The financial accounts of the people using the service are maintained appropriately and receipts are being kept for all purchases. Individuals are supported to manage their money appropriately by the Manager and staff. Records about the care and support provided to people have been maintained, but it was noted that there was not always an entry for each day. It is important to ensure that there is recorded evidence that staff are providing the daily support each person requires and that their needs are being met in all areas of their lives. The Manager confirmed that it had been agreed at a recent meeting that this would now happen. The minutes of this meeting were seen. Alexandra House DS0000013549.V372739.R02.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 People that use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported to participate in the activities they enjoy and to access the local community for their daily activities. People in the home will be supported to have personal relationships if they choose and are supported to maintain any friendships and family contacts they have. They will benefit from their care plans being expanded to include their needs in this area. Everyone using the service is aware of their responsibilities and their rights in the home. People enjoy their meals and have a balanced diet. Alexandra House DS0000013549.V372739.R02.S.doc Version 5.2 Page 13 EVIDENCE: At the time of the inspection all four people living in the home were on their way out to an activity. The staff on duty said they were going to the local red cross centre to help make some poppies for Remembrance Day. The inspector spoke with two people who said they were looking forward to going out to do this. Each person has their own activity planner. These were seen for all four people and were found to include a variety of activities such as Karaoke, cookery, music for health, walks in the park, cafes, pubs and cinema, horse riding and indoor games. The four planners were generally the same with the exception of one persons plan, which also had a daily walk included to improve their mobility. The activity planners had been reviewed in June 2008. The Manager said that the people in the home tend to enjoy the same types of activities. Some new activities have been introduced since the last inspection. These include the use of a local college for sugar craft and pottery courses. The care plan notes for two people showed that they are supported to go out of the home for activities at least four times per week and that other activities are available at home. The records showed that people are supported to do an activity of their choice each day. One person has a photo activity board in the hallway to help them choose and plan their daily activities. Peoples social needs are addressed and met through their care plan. A sexuality policy has been introduced in the home since the last key inspection. This will help staff to understand the issues involved in supporting people with personal and intimate relationships. The Manager said the care plans are to be updated to include these issues. People in the home are supported to maintain contact with their family members through visits, phone calls and letters. Peoples responsibilities and rights in the home are laid out in the terms and conditions and the Service User Guide. People are supported to be as independent as possible around the home and help with household chores and cooking. The privacy of peoples own bedrooms is now being respected. A requirement was made in relation to privacy of bedrooms at the last key inspection and this has now been met. The menus have been reviewed since the last inspection and people are now supported to complete a request sheet each day to choose the meals they would prefer. A record of the meals they have actually eaten is kept in one of the diaries to help the Managers monitor that people are being provided with a healthy diet. The records show the people are generally choosing to have the same meals as each other. The Managers must ensure that everyone knows that they can choose to have a meal that is different to everyone else if they wish. Alexandra House DS0000013549.V372739.R02.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, 20 and 21 People that use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have their health and personal care needs met through their care plan. They are supported to manage their medication safely, but will benefit from staff updating their skills and knowledge through training. People are assured that they will be supported sensitively if they become ill or at the end of their life. EVIDENCE: Health action plans are in place for all service users and these were seen in detail on two peoples care plan files. They had been completed in Jan 08. People that live in the home are registered with a local GP, or a GP of their choice, and it is stated in the Statement of Purpose that they can choose any of the health professionals they use. Individuals personal care needs are described in the care plan and risk assessments are in place as needed. People have been offered the opportunity to use a hairdressing salon in the community since the last key inspection Alexandra House DS0000013549.V372739.R02.S.doc Version 5.2 Page 15 rather than the home visiting hairdresser. Some of the people in the home enjoy this and plan to continue. No one in the home is currently managing their own medication. All medication is administered by the staff on duty. They have completed training and an assessment of their competence, but this was several years ago and updates are required. The Manager is aware of this and will be including this in the planned training needs analysis. The medication records were accurate and complete. Individuals needs and preferences in relation to the end of their life have been sensitively discussed with them and recorded on their file. Alexandra House DS0000013549.V372739.R02.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 People that use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People that live in the home know how to make a complaint if they need to. They are now safeguarded in the home as they are supported by trained and competent staff that are able to meet their needs. EVIDENCE: Two care plan files were inspected and these contained a copy of the complaints procedure along with a symbol version of this. There have been no complaints received by the service since the last key inspection. There have been no complaints received by CSCI since the last inspection. At the last key inspection there was evidence that some of the staff team were not able to effectively support people with their needs due to a difficulty with the English language. A Statutory Requirement Notice was issued in relation to this. At the random inspection on 23rd June 2008 it was found that the registered provider had complied with the notice and that the people in the home were only being supported by staff that could understand and follow the care plan and staff that could effectively communicate with them. Since then the Manager has arranged some English language lessons to help staff members to whom English is their second language. At the random inspection on 23rd June 2008 five of the staff files were inspected and this confirmed that all five had completed Safeguarding Adults Alexandra House DS0000013549.V372739.R02.S.doc Version 5.2 Page 17 training on 27.05.08. There is currently a Safeguarding Adults alert that has yet to be closed, although it is believed by the registered provider that the investigations have been concluded. This needs to be followed up with the relevant lead person for safeguarding in Surrey Social Services to ensure an outcome is recorded. There is a whistle blowing policy in place now that tells staff how to raise concerns with Social Services or CSCI if they need to. A copy of the surrey multi agency Safeguarding Adults policy was in the home. Alexandra House DS0000013549.V372739.R02.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): Standards 24 and 30 People that use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is clean, safe and comfortable for the people that live there. EVIDENCE: The home is clean and comfortable for the people that live there. There is sufficient space in the home to meet the needs of the current residents. There is one ground floor bedroom that is suitable for a person that uses a wheelchair. Risk assessments have been completed to ensure that the home is safe and that any individual risks to people in the home are minimised. Alexandra House DS0000013549.V372739.R02.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): Standards 32, 33, 34 and 35 People that use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people in the home are supported by sufficient numbers of competent and qualified staff to meet their needs. The people in the home are, for the majority, safeguarded by the homes recruitment procedures. They would, however, benefit from more robust practice in relation to obtaining employment references for new staff. People living in the home are supported by trained staff, but would greatly benefit from the staff updating their skills and knowledge to ensure they are providing the best support. EVIDENCE: At the last key inspection it was found that some of the staff employed did not have the English language skills to be able to communicate effectively with the people they are supporting or read and understand the care plans. A Statutory Requirement Notice was issued in relation to this. At the random inspection on 23rd June 2008 it was found that the Notice had been complied with. The Alexandra House DS0000013549.V372739.R02.S.doc Version 5.2 Page 20 Manager has since also made arrangements for any new staff to undertake English language lessons if they require this. The Statutory Requirement Notice also required the registered person to ensure that appropriate checks were made when recruiting new staff and that evidence of these checks is held on record in the home. At the random inspection on 23rd June 2008 five staff files were inspected and found to contain the appropriate evidence. At this key inspection the recruitment files for a further three new employees were inspected. These contained evidence that the required checks had been made. However, as a recruitment agency is used to recruit staff from overseas, the original references are not supplied to the care home. The agency translates any references into English and provides the translated version to the care home. The Managers of the home should ensure that a copy of the original reference, showing where the reference came from, be obtained from the agency alongside the translated version. This will help the Managers to ensure that references obtained are authentic and reflect the employment history of applicants. One persons application form did not give clear information about their previous employment history and there was not a reference from the most recent employer. The Manager must ensure that a written reference is obtained from the most recent employer and that any employment gaps or discrepancies on the application form are checked with the applicant. The three new employees are currently working on their skills for care induction. An example of a completed induction was seen. The training files for three staff were inspected. These showed that they had completed the core training they needed to safely support the people in the home, but that some of the courses had been undertaken some years ago and require updating. The Manager stated that a full training needs analysis was being carried out for all the staff in the home within the next two weeks in order to develop a training plan for the next six months to a year. Evidence was seen in the management meeting minutes that this had been agreed with timescales. One staff member, who was in the home at the time of the inspection, described a number of recent training courses that they had completed, but a copy of the certificate for these courses had not yet been placed on file. The Managers must ensure that there is evidence on file for all the training staff complete. Some of the staff team have either completed the NVQ or are working toward this. The Manager stated that the three new staff members will be enrolling on the NVQ award when they complete their induction. The staff rota was examined for a two week period for October 2008. This showed that there are always three staff on duty for the four people living in the home. The rota still does not always reflect the actual hours the Managers works at the home as sometimes the planned shifts change. The rota must be Alexandra House DS0000013549.V372739.R02.S.doc Version 5.2 Page 21 updated following any changes to ensure there is an accurate record of the hours worked in the home. Alexandra House DS0000013549.V372739.R02.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): Standards 37, 39 and 42 People that use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home benefit from a service that is run by qualified and competent managers, but will benefit from the Managers demonstrating that they can sustain the recent improvements made to the service. They are consulted on their views of the support they receive and can have a say in how their service is run. The health and welfare of the people in the home is promoted and protected. EVIDENCE: There are two registered Managers for the home. Both hold a relevant care and management qualification and have many years experience of supporting people with learning disabilities. Since the last key inspection the Managers Alexandra House DS0000013549.V372739.R02.S.doc Version 5.2 Page 23 have made many improvements to the service and have made arrangements to keep up to date with the latest good practice guidance through the subscription of a learning disability journal. The Manager said they are also looking to implement some guidance produced by the Tizard centre on person centred active support. This will greatly benefit the people living in the home. A care management consultant is now also being used to audit the quality of the service on a monthly basis and feed the results back to the management meetings. The care consultant is providing guidance and advice on good practice issues and current legislation. A number of changes have been planned to improve the service, including a training needs analysis and a review of the record keeping in the home. A quality assurance audit took place in May 2008 where the people living in the home, their relatives and any health professionals were asked to give their views of the service. A report of the findings was produced. Three people had commented in their surveys that they did not know how to make a complaint if they needed to. This was not reflected in the findings report. The Manager should ensure that matters such as these are reflected in the report and that the action taken to address issues is recorded. The health and welfare of the people using the service is addressed through their individual care plans and risk assessments. There are no areas of health and safety concern in the home at present. Overall the Managers of the home have made significant improvements to the service provided at Alexandra house. The Statutory Requirement Notice and all the requirements made in the previous inspection report have been complied with. The Managers have demonstrated a commitment to modernising the service provided and they should continue to focus on developing the service further to ensure that peoples needs are addressed in all areas of their lives in a person centred way. The Managers should be able to demonstrate at the next key inspection that these improvements have been sustained and that the lives of the people living in the home have improved as a result. Alexandra House DS0000013549.V372739.R02.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 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 2 X 2 X X 3 X Alexandra House DS0000013549.V372739.R02.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA34 Regulation 19(1) Requirement The registered person must ensure that the employment history of employees is obtained and confirmed with the employee and that a reference is obtained from the most recent employer. Timescale for action 14/11/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA7 Good Practice Recommendations It is recommended that the care plans be further expanded to include peoples needs with regard to personal relationships and their sexuality. It is recommended that person centred planning be used to help people make wider decisions in their lives and decisions about their futures. Alexandra House DS0000013549.V372739.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone 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 Alexandra House DS0000013549.V372739.R02.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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