Inspection on 09/06/07 for Bedfordshire Cheshire Home

This inspection was carried out on 9th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Bedfordshire Cheshire Home 15/11/05

Bedfordshire Cheshire Home 26/06/05

Bedfordshire Cheshire Home 23/03/05

Bedfordshire Cheshire Home 27/07/04

Bedfordshire Cheshire Home 29/03/04

Similar services:

Claremont House

Sun Court Nursing Home

Bramley Avenue (73)

15 Bramble Close

Dolphin Court

Fen Road

Wakes Hall

165 Putnoe Lane

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

CARE HOME ADULTS 18-65 Bedfordshire Cheshire Home Agate House Woburn Road Ampthill Bedfordshire MK45 2HX Lead Inspector Carol Mitchell Unannounced Inspection 9th June 2007 09:40 Bedfordshire Cheshire Home DS0000017666.V342503.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 Bedfordshire Cheshire Home DS0000017666.V342503.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. Bedfordshire Cheshire Home DS0000017666.V342503.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bedfordshire Cheshire Home Address Agate House Woburn Road Ampthill Bedfordshire MK45 2HX 01525 403247 01525 840244 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.leonard-cheshire.org.uk Leonard Cheshire Mrs Sue Ellis Care Home with nursing 33 Category(ies) of Physical disability (33) registration, with number of places Bedfordshire Cheshire Home DS0000017666.V342503.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Specialist Care for Severe Physical disabilities, for 12 persons. The home is permitted to accommodate up to and including 3 people who are 65 years of age and over within the category of Physical Disabilities (PD). The purpose of this condition is so that the home can continue to care for people when they reach their 65th birthday. 15th November 2005 Date of last inspection Brief Description of the Service: Bedfordshire Cheshire Home is a purpose built single storey home for service users with a physical disability. All the rooms are for single occupancy and five rooms have en-suite facilities. All the rooms have a small-designated garden/patio area. The home is split into four areas that all have their own communal lounge/dining, kitchen, bathroom and toilet facilities. In addition, the home has various other rooms for recreation, activities and therapeutic interventions. The home is situated on the outskirts of Ampthill with good road links to local towns and the motorway. The home has attractive grounds and ample parking. The home has a designated respite/short stay placement and also offers day care for up to three service users. The home also has transport available for accessing community services and leisure facilities. The home is part of the Leonard Cheshire Foundation. Major refurbishment works are planned as a result of which rooms will have en-suite facilities in the future. Work commenced the week following the inspection visit. The following information about fees was obtained on 9th June 2007:Minimum fee £845, Maximum fee £1028. The following items are not included in the fees:hairdressing; private chiropody; transport; newspapers/magazines; holidays; theatre/cinema. Further information about this home can be obtained by contacting the home direct by telephone or email, or by visiting. Bedfordshire Cheshire Home DS0000017666.V342503.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report takes account of information received by the Commission since the last main inspection on 15th November 2005, and from the inspection visit. Information received includes 13 questionnaires completed by residents during December 2006, and 3 questionnaires completed by residents or their representatives during the inspection visit. (Additional questionnaires were also left at the home, and 6 were returned.) The manager provided information during December 2006, and also completed the Commission’s quality assurance self assessment document in May 2007. The unannounced inspection visit took place on Saturday 9th June 2007 during a period of around 3 and a half hours. During the visit the inspector spoke with residents, relatives and staff. The manager was present during some of the visit. The inspector also checked some records, and looked around some parts of the building. The inspector would like to thank everyone involved with the inspection visit. What the service does well: The home is really good at letting people be as independent as possible. People like living at the home. A resident said, “I go to the day centre for two days every week. I can go wherever I like.” Other residents said, “I really enjoy being at the home, and I enjoy the trips out”; “I have just been away and I am really glad to come back”. People are encouraged to see their family and friends as much as they want to, and family members say that they are made to feel very welcome, and can go to the home at any time. People living at the home are involved with how it is run. They have meetings and decide about things like activities and trips out, and what should be on the menu. Lots of meetings have been held about the building work that is currently being done at the home. Information days are also held to make sure that everyone knows what is going on. People have chosen decoration schemes and colours for their rooms. Bedfordshire Cheshire Home DS0000017666.V342503.R01.S.doc Version 5.2 Page 6 People living at the home feel that it is very easy to speak up and complain if necessary. One resident said, “Of course I know how to complain and I speak up!” Another said, “I know I can speak to any member of staff and they will help me if I have any problems.” The home has a very good “Have Your Say” leaflet to help people understand about how to make a complaint. The home makes very sure that people’s health needs are well catered for. People at the home have a key worker of their choice if they want one. A resident said, “I have got good health care here.” Very good care plans are written, and different members of the health care team support residents and help them to keep as healthy as possible and to live as independently as possible. The manager is very experienced, and the staff receive training and support. They are a good team and they like their work. Staff members said, “The training here is first class, and so is the support from the manager and owner, I can go to the manager about anything, and I am listened to”; “I love it here!” What has improved since the last inspection? What they could do better: The manager is keen to keep on checking that the home is run in the best way. For example she is going to make sure that the key worker system, and the individual service plans keep working in the best interests of people living at the home. Bedfordshire Cheshire Home DS0000017666.V342503.R01.S.doc Version 5.2 Page 7 The building is now 30 years old and will benefit from the considerable refurbishment planned. The manager wants to improve some more of the written information, such as the application pack, by producing it in alternative formats. The current meal times are being reviewed with residents. Some residents and staff are trying to encourage improvements to the access of some local buildings. 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. Bedfordshire Cheshire Home DS0000017666.V342503.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 Bedfordshire Cheshire Home DS0000017666.V342503.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is very good at making sure that all the proper assessments are done before anyone is allowed to move into the home. Therefore, people living at the home can be sure that their needs and aspirations will be met. EVIDENCE: Prospective residents are sent a pack with lots of useful information including a current newsletter, and a brochure. Members of the multidisciplinary teams are asked to complete full assessment reports regarding any resident who wishes to move into the home. The home’s manager also visits the person, and their carer if the person wishes, to complete a full assessment of needs and aspirations to make sure that the home would be the right place for them. Visits and overnight stays can be arranged and the whole process is managed in a very individual and personal way. At the time of the inspection visit, the application pack was under review. In particular the manager is keen to develop alternative ways of presenting the information given. A full assessment had been completed for a resident receiving respite care. Contracts are issued. Bedfordshire Cheshire Home DS0000017666.V342503.R01.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): 6, 7, 8, 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager makes sure that everyone has a really good working care plan that they agree with. People at the home are helped to live as independently as possible, and residents can do the things they want to. Therefore people living at the home know that their changing needs will be met. EVIDENCE: Residents at the home help with the development of their Individual Service Plan, when they first move in, and at subsequent reviews. If the resident wishes, family members are also involved. The manager and staff help residents to explore opportunities available to them, and they explain people’s right to take risks when living at the home. Risk assessments are done, and risks are minimised as much as possible. A small sample of individual service plans showed that great attention is paid to the specific and detailed needs and aspirations of residents. Any difficulties with communication were Bedfordshire Cheshire Home DS0000017666.V342503.R01.S.doc Version 5.2 Page 11 assessed and information and advice were detailed and specific. Individual risk assessments were in place and had been regularly reviewed. The words of residents were recorded in plans for example “I would like to improve my communication skills”. The care plans at the home are well organised, comprehensive, individual and meaningful documents. Residents spoken to indicated with absolute confidence that they make choices all the time about their lifestyle, and that the opportunities available to them are viewed very positively. They knew about the key worker system and were able to name their key worker. The home’s annual survey gave positive results regarding people’s ability to make decisions and have control over their lives. For example residents are able to control their money with support if necessary, and choose décor and furnishings. Residents told the inspector about colour and other choices they had made for their new rooms. Residents indicated that they expect to be fully involved, and they are. The home wishes to make more of its information available in different formats and the manager has started work in this area. The home invites residents to participate in the running of the home through meetings and in other informal ways. For example the home is imminently to undergo major building works, and residents have been closely involved at each stage in the process. At the time of the inspection visit plans were displayed for everyone to see, and residents spoken to knew in detail about the scheduled works and how it is likely to impinge on their personal circumstances. (The home is planning additional trips and activities away from the home to lessen the exposure to noise and disruption.) Bedfordshire Cheshire Home DS0000017666.V342503.R01.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): 12, 13, 15, 16, 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager and staff make sure that the opinions of residents come first. Therefore people living at the home are able to take part in activities of their choosing, and they enjoy life at the home. EVIDENCE: Residents can attend college if they wish, and in the large activities/craft room computers are available. A large range of activities is provided in the home in a well organised and structured way. Recently there have been themed evenings including a fashion show and, film night and barbeque. Some residents had been due to go to a concert on the evening of the inspection visit, but unfortunately the singer cancelled the event. A resident told the inspector that she is more independent at the home than she had been in the community. Residents are able to go to pubs and shops in Ampthill, although Bedfordshire Cheshire Home DS0000017666.V342503.R01.S.doc Version 5.2 Page 13 wheelchair access is sometimes difficult. One of the home’s residents has led a local campaign to improve pathways in the locality. The home has the use of 4 vehicles. Relatives visiting on the day of inspection confirmed that family members and friends are made very welcome at the home at any time. They are welcome to accompany residents on trips out. Meetings with residents are held, and a resident confirmed that these are productive events. Lots of matters are discussed including agreeing the schedule for activities and trips out. Minutes are taken at meetings, and a newsletter is produced. Information days are also held, more regularly recently since the building works are now imminent. During the inspection visit residents enthused about their life experiences at the home. When asked, they could not think of anything they wanted to change. A resident told the inspector that she had just returned from an exchange visit to another home in the group. The driver was ready to take residents to the superstore. One resident explained that she is off to Spain on holiday later in the year. One resident was working at the computer in the activities room. On the afternoon of the inspection visit the home was to host a craft fayre. Menus are routinely agreed with residents and there is a monthly menu review meeting with residents to formally discuss and agree the forthcoming menus. Feedback from these meetings has led the manager to consider ways of introducing more flexibility into the timings of meals. Bedfordshire Cheshire Home DS0000017666.V342503.R01.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): 18, 19, 20, 21 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager and staff are flexible in their approach and really want people living at the home to have choice in the way they are supported. Therefore residents’ personal and health care needs are met in an individual way, and residents and their families are very pleased. EVIDENCE: Residents are encouraged to go to their choice of family doctor, optician, dentist, hair dresser and so on, and facilities are provided within the home for some residents. Individual service plans are well written and include specific details regarding the health and personal care needs of residents. Residents indicate how they would like their care to be provided, and staff are flexible in order to meet their wishes. There is a key worker and a named nurse system in place, and if residents want one, they have a key worker of their choice. Input from specialists and the multidisciplinary team is referred to, and a resident and her Bedfordshire Cheshire Home DS0000017666.V342503.R01.S.doc Version 5.2 Page 15 mother confirmed that excellent attention is given to her health and personal needs. The resident described frequent liaison with the home’s physiotherapist, an occupational therapist and the home’s health and safety person. Instructions about clinical interventions were clear and specific within individual service plans. The emotional needs of residents were also reflected in the plans including ways of reducing feelings of anger. Special information is prepared for use by unfamiliar or agency staff in individual situations when this is assessed as necessary. Special communication aids are used to help some residents, for example communication cards and light writers. Well thought through comprehensive documents regarding residents’ end of life choices are compiled with the input of family members when appropriate. One resident currently chooses to administer his own medication, and an internal audit has recently checked that this is being safely managed. The medicines are well organised, regularly checked, and the providing pharmacist does inspections. Registered nurses administer medicines to those who are not self-administering. Bedfordshire Cheshire Home DS0000017666.V342503.R01.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): 22, 23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager makes sure that people living at the home are supported and actively encouraged to speak up. Therefore residents are certain that they will be listened to. EVIDENCE: The home’s quality assurance activity indicated a need to improve residents’ awareness regarding the complaints process. Having obtained feedback, the home has set about improving things further for residents. The home has reproduced its “Have Your Say” leaflet. It is very straight forward and is illustrated with clear symbols to aid understanding. The leaflet has been reissued to each resident, and each person’s understanding about how to compliment or complain about the service they receive has been checked. There are plans to make the leaflet available in other formats. Residents spoken to during the inspection visit communicated their ability to speak up with absolute confidence. Residents know that what they think and feel is most important and it is their firm expectation that they will be listened to. The individual needs of residents are understood and clearly and comprehensively communicated in such a way that isolated episodes of Bedfordshire Cheshire Home DS0000017666.V342503.R01.S.doc Version 5.2 Page 17 aggressive behaviour are prevented and minimised. Communication includes making sure that agency staff have clear and easily accessible information. There is a set procedure for dealing with complaints, and all staff attend training about the protection of vulnerable adults. Staff questioned were very clear about what they would do if they are concerned about the treatment of a resident. Since the last inspection visit two issues were referred in the correct manner to the protection of vulnerable adults team. Both were resolved satisfactorily, and neither investigation found that staff were at fault in any way. The proper checks are made before employing any new staff. No complaints have been received since the last inspection visit. Bedfordshire Cheshire Home DS0000017666.V342503.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. Every effort is made to maintain the home and keep it comfortable at all times including during the works to be done. The manager is very aware of the impact of the works on residents and will do her best to manage the situation well, including briefing the building firm about the needs of residents, and arranging time out from the noise and disruption. Therefore people at the home can be sure that they will be living in a safe and maintained environment, although there may be some difficult times ahead. EVIDENCE: The inspection visit took place just before major refurbishment works at the home commenced. Plans for the works were on display, and these were shown to the inspector by residents. Residents were fully informed about the works, how they will be individually affected, which room they will move to, and when. Whilst not dissatisfied with the current accommodation, residents Bedfordshire Cheshire Home DS0000017666.V342503.R01.S.doc Version 5.2 Page 19 were pleased and excited about the planned improvements, which will mean larger bedrooms, the addition of en-suites, and improved wheelchair accessibility among other changes. The manager has planned extra activities and trips out for residents during the works to alleviate residents’ exposure to the inevitable disruption. Surroundings for residents at the time of the inspection visit were comfortable. Residents indicated that the home is well maintained and were able to name the person who will fix things that go wrong. A resident explained that a toilet had been especially altered to allow her more independent access to it. The parts of the home seen were clean, and there were no odours. Laundry equipment was in full working order and was manned on the day of the inspection visit, which was a Saturday. Designated cleaning and laundry staff are employed at the home. Staff receive training in infection control. Bedfordshire Cheshire Home DS0000017666.V342503.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, 36. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager makes sure that the staff know the needs of residents really well, and that they receive specific training to help them. Staff work in a very organised way for the benefit of residents who therefore know that they have a well supported and supervised staff team at the home. EVIDENCE: Staff present during the inspection visit were attentive and professional in their manner when dealing and communicating with residents and others. When questioned they were able to describe residents’ individual and detailed needs, and they were clear about their role in the organisation. They had received training. Residents and family members indicated that relationships with staff are very positive indeed. They knew the name and role of their individual key workers, and reported that someone is employed to deal with all of their needs. Bedfordshire Cheshire Home DS0000017666.V342503.R01.S.doc Version 5.2 Page 21 The duty rota is arranged flexibly so that the changing needs of residents can be met. There is some use of agency staff. However efforts are made to always use the same staff, and the needs of agency staff are given attention by the manager as described elsewhere in this report. Training is given high priority at the home, and is geared to the needs of residents so that if a particular topic needs covering, training is arranged and given to staff. Care staff are encouraged to achieve National Vocational Qualification training, and about 50 of care staff had achieved this at the time of the inspection visit. Staff have meetings, there is a staff association group, and staff feel well trained and supported. They are able to make suggestions to the manager and owners, and they feel listened to. Supervision sessions are held regularly, and supervisors have all received training for the role. Staff spoken to really enjoy their work at the home, and they describe strong team work. Thorough recruitment processes are followed when employing staff and the proper checks are made before anyone can start working at the home, including registered nurses. A sample of staff files was in good order, and included individually tailored job descriptions for each role. Bedfordshire Cheshire Home DS0000017666.V342503.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, 38, 39, 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager is experienced and well qualified, and the home is run in ways which really value residents’ opinions and rights. Therefore people living at the home can be very sure that it is run with their best interests at heart. EVIDENCE: The manager is a registered nurse who is well qualified and experienced for the post and her qualifications include a diploma in multiple sclerosis care. The manager is friendly, approachable, well known and liked by residents, staff, family members and others. Bedfordshire Cheshire Home DS0000017666.V342503.R01.S.doc Version 5.2 Page 23 The manager is supported by staff at the home, including help for administrative and health and safety duties, and also by senior personnel from the organisation. For example there is a training manager and a human resources adviser. The manager feels very well supported and has many opportunities for her training and development. The management style at the home is open, inclusive, organised and respected. Residents expect to be involved in all aspects of the running of the home, and they are. The home is run with residents’ needs at the heart of decision making. For example the key worker and named nurse system is well established for the benefit of residents. Residents have meetings which they reported are helpful, meaningful and vibrant affairs. Resident meetings to address particular issues are also held. For example there are monthly meetings to decide on forthcoming menus, and weekly meetings to decide on and schedule activities. As a result of recent feedback from a meeting, the meal timings are currently being reviewed. The home operates a structured quality assurance programme including an annual survey for quality assurance, the results of which are compiled into a published report, feedback given and actions taken accordingly. For example, the “Have Your Say” leaflet was improved following feedback relating to people’s knowledge of the complaints procedure. Bedfordshire Cheshire Home DS0000017666.V342503.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 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 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 x 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 3 4 3 3 x x 3 x Bedfordshire Cheshire Home DS0000017666.V342503.R01.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bedfordshire Cheshire Home DS0000017666.V342503.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Bedfordshire Cheshire Home DS0000017666.V342503.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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