Inspection on 28/03/08 for Bluecoats (18)

This inspection was carried out on 28th March 2008.

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

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

Bluecoats (18) 25/04/06

Bluecoats (18) 10/10/05

Bluecoats (18) 05/04/05

Bluecoats (18) 16/08/04

Bluecoats (18) 18/05/04

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 Bluecoats (18) Thatcham Berkshire RG18 4ND Lead Inspector Amanda Longman Unannounced Inspection 28th March 2008 10:45 Bluecoats (18) DS0000011192.V357583.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 Bluecoats (18) DS0000011192.V357583.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. Bluecoats (18) DS0000011192.V357583.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bluecoats (18) Address Thatcham Berkshire RG18 4ND 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) 01635 874266 ainsley.bowles@new-support.org.uk www.new-support.org.uk Dimension (NSO) Ltd Mrs Ainsley Simone Bowles Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Bluecoats (18) DS0000011192.V357583.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th April 2006 Brief Description of the Service: Bluecoats is a purpose built single storey property located in a quiet area but close to the centre of Thatcham. The home has six single bedrooms and provides care and accommodation for up to six people who have learning and physical disabilities. The Service Users are aged between 18 and 65 years of age. The home has a kitchen/ dining area and a lounge. There is a laundry room. The rear garden is large and well maintained with a raised garden suitable for wheelchair users. There is parking and a small-grassed area to the front of the property. There is wheelchair access to the garden. The home has policies and procedures in place to address equality and diversity issues. The current fees for the home will be recorded in the final report. Bluecoats (18) DS0000011192.V357583.R01.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 2 stars. This means the people who use this service experience good quality outcomes. This inspection of the service was an unannounced ‘Key Inspection’. It was a thorough look at how well the service is doing. A site visit was undertaken on 28 March 2008. During this site visit we (the commission) talked to everyone who lives at Bluecoats. We looked round the home and watched how staff support people. We also talked to the acting manager and another member of staff and we looked at some written records. Before we went to the home the manager had sent us a lot of information about the home and how it works. This information is called the Annual Quality Assurance Audit or AQAA. We also received completed surveys from five people who live at Bluecoats, from four relatives, from four staff members and from one health professional. All of these provided information about the quality of care provided at Bluecoats. The home has a very homely relaxed atmosphere. At the time of the inspection the home was being managed by the deputy manager as the registered manager is currently seconded to another project. What the service does well: What has improved since the last inspection? No requirements were made at the last inspection. Bluecoats (18) DS0000011192.V357583.R01.S.doc Version 5.2 Page 6 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. Bluecoats (18) DS0000011192.V357583.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bluecoats (18) DS0000011192.V357583.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. Service users have all the information they require about the home to make a decision about moving in to it. Their needs are fully assessed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information from the Annual Quality Assurnace Assessment(AQAA), completed by the registered manager, stated that one person had moved in to the home since the previous inspection. Information received from surveys stated all the people living in the home had had enough information, came to visit, met staff and other residents and were asked if they wanted to move in to the home, prior to actually moving in. We confirmed that one person has moved in to the home since the previous inspection. This person confirmed they had had sufficient information about the home and had come to visit it before moving in. The home had undertaken a full assessment of their needs. Bluecoats (18) DS0000011192.V357583.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. Individuals make decisions about their own lives, and play an active role in planning the care and support they receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This area was judged as provding good outcomes at the previous inspection. The AQAA we received stated each person is treated indvidually, their choices are met and respected, for meals, clothes, likes, dislikes, hobbys and they are supported in how they live their life generally. 100 of the surveys we received from residents stated they have support to make choices. However only 25 of staff surveys received said there were always enough staff to meet indivividual needs, although an additional 50 said there usually was. On the day of the site visit we looked at support plans relating to two people who live at the home. They are very detailed and contain residents likes and dislikes and personal choices. The deputy manager and one member of staff were spoken with. Both demonstrated a commitment to support individuals to Bluecoats (18) DS0000011192.V357583.R01.S.doc Version 5.2 Page 10 live the life they choose and both were knowledgable about diversity issues and respectful of peoples personal relationships. There is a detailed support plan for each aspect of the individuals care and for each activity and an associated risk management plan. Use is made throughout the plans of symbols and photographs to assist in understanding. Staff sign each support plan to confirm they have read and understood how the person wishes to be supported. The support plans are reviewed with each resident who meets regularly with their key worker (at least once every two weeks). Each resident has their own file in their rooms with information relating to their care and some residents choose to keep the notes from their key worker meetings in these files. One resident chooses to keep their notes on their computer and another on tape. Three service users have started going to a weekly advocacy group to help ensure the home addresses their individual wishes. On the day of the site visit there appeared to be sufficient staff to meet individuals needs. We spoke with the deputy manager who felt their were sufficient staff to meet individuals needs and that one to one meetings with key workers enabled any unmet needs or wishes to be identified and planned for. We spoke with all the people who share the home who all have different levels of verbal and non verbal communication and observed their interactions with staff throughout the day. We concluded that each individuals needs are well met. Bluecoats (18) DS0000011192.V357583.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. Individuals make choices about their life style, and are supported to develop their life skills. People enjoy the social, educational and recreational activities on offer. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Following the previous inspection outcomes for residents in this area were judged to be good. In their AQAA the manager told us that all the people living in the home have an individual path which details their hobbies, choices and regular activities; that they have supported three people with communication aids to attend college and that indviduals are supported to count their money, write shopping lists, and letters. The AQAA also stated that the people who live at Bluecoats take part in the local community, by, for example, going shopping, to the pub, the doctors and swimming; that they use a good local taxi firm if there are no drivers on shift, or use the local low ride buses, or trains. The AQAA stated Bluecoats (18) DS0000011192.V357583.R01.S.doc Version 5.2 Page 12 that family and frinds are welcomed in to the house and that everyone who lives at Bluecoats has a key to the house. It also stated that all the peoplle who live there take an active part in the prepration of any food and house cleaning that is being done and that a picture menu in place. 100 of residents who replied to the surveys we sent out confirmed that they can do what they want every day and evening. A concern raised by one relatives who responded to our survey was that there were not enough drivers to meet individual needs and and that full group holidays are not appropriate for some individuals. On the day of the site visit we looked at two of the individual paths. They were detailed and up to date. Two people were at college during the morning of the site visit. We spoke with them on their return. They had been doing computer skills and both very much enjoyed going to college. Another person was out having a haircut and on their return we sat with the person and member of staff while the money spent was recorded appropriately. There are lots of photographs in the home of people enjoying different activities. An events calendar in the hall displays forthcoming events and each individual has an appointments and activies diary which staff assist them to keep up to date. Other examples of activities include two people who are going to watch London Irish Rgby at the weekend; a 2.5 mile sponsored challenge recently undertaken (we saw photographs and medals of this event which people said they enjoyed) and supporting one person to go to a Kylie Minogue concert. On the day of the site visit everyone was looking forward to the evening because they were all going to a ball. Two people showed us the outfits they were going to wear and a hairdresser was coming to the home to help people to do their hair for the ball. We discussed the availablity of a driver. The home employs a part time driver/handyperson and tries to also have a driver on each shift. The deputy manager also confirmed they use low ride buses and taxis. We also discussed the arrangements for holidays. They are not organising a whole group holiday this year as individuals want to do different things. One holiday has so far been arranged for this year for two people who wish to holiday together. The deputy manager and staff confirmed that people can have visitors when ever they wish. Individuals are supported to enjoy relationships with family and friends. Some people stay with relatives on a regular basis. We discussed the homes approach to personal relationships with the deputy manager who confirmed they support each individual’s personal relationships of their choice. Everyone has a key to their room and to the front door. Bluecoats (18) DS0000011192.V357583.R01.S.doc Version 5.2 Page 13 People living at the home participate in the running of the home and evidence was seen of people helping with chores around the home. Everyone is registered to vote and information from all parties about local elections is available for people in the home. There is a picture menu on display in the kitchen and photographs of individuals preparing food. On the day of the site visit one person made their own lunch. All staff have food hygeine training. The most recent environmental health inspection was over three years ago but recorded excellent in all respects. Individuals confirmed the food was good. People in the home seem very happy. Bluecoats (18) DS0000011192.V357583.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 and 20. Quality in this outcome area is good. Individuals receive personal support in the way they prefer and their healthcare needs are fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Following the previous inspection, outcomes for residents in this area were judged to be good. In their AQAA the manager told us that each individual has an in depth support plan which highlights how and when the person likes something to be done, and that each person has a Health Action Plan, to support their health needs. We received one completed survey from a healthcare professional which stated that the home tries to advocate to improve people’s healthcare; that medication is handled appropriately; that staff have the right skills and experience to support health care needs and that they can meet diverse needs. We viewed two people’s support plans. Each persons plan details their preferences for how they are supported. Including for example getting in to or out of bed, personal care and continence care. These support plans are detailed covering any relevant background information and guideleines which Bluecoats (18) DS0000011192.V357583.R01.S.doc Version 5.2 Page 15 incorporate risk reduction management. Medication is included in the support plans. Support plans include detailed information about health care needs and appointments. We discussed with the deputy manager how they would cope with religious or cultural needs relating to personal or health care. The home has a diverse staff group and would also seek advise in such situation and is confident they could provide appropriate care. The home is developing Health Passports with assistance from the learning disability nurse, these are small passport sized booklets which may be carried by individuals and contain their essential health information and details of how they prefer support to be given. Bluecoats has appropriate medication procedures in place. Medication records were checked for two individuals and were in order. Medication is appropriately stored. Staff have received training in the administration of medication and it is always administered by two people as a way of checking it is administered appropriately. Bluecoats (18) DS0000011192.V357583.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): Quality in this outcome area is good. 22 and 23. Individuals feel that their views are listened to and they are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Following the previous inspection, outcomes for residents in this area were judged to be good. In their AQAA the manager told us that they give people the chance to make a complaint, follow these complaints through, and detail all action taken. The AQAA also stated that staff attend training about safeguarding vulnerable adults and that these issues are discussed in staff meetings. People living at the home and other relevant people (eg parents) have been given a copy of the complaints procedure. In the pre-inspection surveys which were returned, 80 of people living at the home stated that they knew who to speak to if they were not happy. 100 of the relatives who returned a survey stated they knew how to complain and 100 stated comments were usually or always dealt with appropriately. Peoples money is protected. Each person has an account book where all transactions are logged. Expenditure is receipted and the receipts are signed by individuals where they are able. Entries in financial transaction books are signed by two members of staff and audited by the home every month and by head office periodically. Bluecoats (18) DS0000011192.V357583.R01.S.doc Version 5.2 Page 17 The home has a complaints procedure in place. Key workers discuss with each individual whether or not they are happy and use pictorial symbols where appropriate to assist with undertstanding. Each person has access to stamped addressed postcards which they can send to Dimensions head office if they wish to complain direct to them. CSCI has not received any information relating to complaints made since the last inspection. Bluecoats has an appropriate procedure in place to protect individuals which is in line with the local multi agency guidelines. It also has procedures relating to whistleblowing. Staff spoken with were familiar with correct procedures to follow should they suspect anybody at the home was subject to any sort of abuse. Bluecoats (18) DS0000011192.V357583.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, 25, 26, 27, 28 and 30. Quality in this outcome area is good. People enjoy a homely, comfortable, safe and clean environment which meets their needs and promotes independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Following the previous inspection, outcomes for residents in this area were judged to be good. In their AQAA the manager told us that they have a homely atmosphere, with pictures around the home and that the people who live at the home choose the décor for communal areas and for their own bedrooms. The AQAA confirmed that all electrical, hoist, fire and other equipment is serviced in line with the manufacturers recommendations and everything was serviced in 2007. They have purchased two large industrial washing machines to suit the needs of the people who live there. All the surveys received form residents stated the home is fresh and clean. Comments from relatives included the wish for a visitors room for privacy and that the home would benefit from en suite bathrooms. However the comment was made that they “do there best within the resources avilable”. Bluecoats (18) DS0000011192.V357583.R01.S.doc Version 5.2 Page 19 The home employs a part time handyperson (18 hous) who was changing a kitchen strip lighting bulb on the day of the site visit. He undertakes scheduled maintenance and garden maintenance. There is a contract with the landlord for external maintenance. The home is a bungalow which is fully wheelchair accesible. On the day of the site visit we viewed three bedrooms with their residents. All were individually decorated and suitable for their individual needs. For example track hoists were in place and one room had a variety of sensory equipment. Some rooms had net curtains and staff confirmed this was down to individual preference. We were shown round the communal areas which comprise a lounge, a kitchen dining room, one bathroom, one shower room and one cloakroom. All were suitably equiped. One of the light pull switches was dirty. We told the deputy manager about this who agreed to change it by the following day and the shower room had an odour from the special bins for incontinence pads. We discussed with the deputy manager alternative means of storage to prevent the odour and they agreed to take this up with the contractor as a matter of urgency. With these two exceptions, the house was fresh and clean. The house was comfortable, homely, decorated with photographs of the people who live there and paintings done by them. Individuals confirmed they liked living at the home. There is a large level garden with raised flower beds. The deputy manager stated that the garden is used a lot in the summer and this was confirmed by people sppoken with and photographs around the home. Bluecoats (18) DS0000011192.V357583.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 and 36. Quality in this outcome area is good. People at the home benefit from being supported by competent, well-trained staff who are appropriately recruited and supervised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Following the previous inspection, outcomes for residents in this area were judged to be adequate. In their AQAA the manager told us they have a recruitment procedure in place and that all appropriate pre-employment checks are completed for new staff. They also told us that someone who lives at the home takes part in all interviews and decisions about whether or not to offer a job. The AQAA states “.. it is somebodys home and is to be treated as such,..” . During the site visit we confirmed that Bluecoats has an appropriate recruitment procedure in place. We looked at the recruitment records for the most recently recruited member of staff which showed all appropriate preemployment checks had been completed. The home currently has one vacancy for a senior support worker and interviews for this post and for bank staff had been arranged for the following week. The vacancy is currently being covered by regular bank staff who know the people at the home well. Bluecoats (18) DS0000011192.V357583.R01.S.doc Version 5.2 Page 21 Almost 50 of current staff (6 out of 13) are qualified to a minimum of NVQ level 2, with four of these being qualified to NVQ level 3. New staff follow an induction course called “Our Approach” which is in line with the Skills for Care Common Induction Standards and is accredited by City and Guilds. Further training is provided in all mandatory subjects including first aid, manual handling, health and safety and the safeguarding of vulnerable adults. Updates and refresher training is planned ahead for all staff and medication competence is tested every six months. Records seen on the day of the site visit confirmed that all training is in place. Supersvions are carried out monthly for each staff member following a procedure called “Our Way Of Working”. Staff spoken with confirmed they felt well supported. Observations on the day showed that staff work well with the people living at the home and all the surveys from individuals stated that staff always treat them well and listen and act upon what they say. Surveys from relatives and one health professional stated that staff usually have the right skills and experience to meet individual needs and that the staff and manager are very caring. We looked at the rotas for a random day and there were at least four staff on duty at all times including the deputy manager. We were informed this is sometimes a minimum of three staff. There are always two staff on duty at night. The part time hadyperson/driver is in addition to this staff complement. Bluecoats (18) DS0000011192.V357583.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. Individuals benefit from a well run home and can be confident their views are listened to. Their health, safety and welfare are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Following the previous inspection, outcomes for residents in this area were judged to be good. In their AQAA the manager told us that they work in a open and transparent way and that team work has improved and there is better communication. Staff surveys received confirmed that the manager is “encouraging” and “always there to listen”. However, the registered manager has been seconded to a Dimensions project from the beginning of February 2008 until approximately May 2008. The deputy manager is currently the acting manager. The registered manager is still in regular contact with the home and was present for part of the time Bluecoats (18) DS0000011192.V357583.R01.S.doc Version 5.2 Page 23 during the site visit, but the deputy manager manages the home on a daily basis. The deputy manager is qualified to NVQ level 3, is currently undertaking an A1 Assessors award and has studied courses in social care. The home has a variey of mechanisms for monitoring quality assurance at Bluecoats. The deputy manager stated residents meetings were not found to be working as people were talking over each other and getting cross. Each person meets with their key worker once a week or once every other week and has a discussion about issues such as whether or not they are happy, if there are other things theyd like to do, matters about the running of the home and plans for the future. These meetings are noted either in writing, on the persons computer or on tape, according to the wishes of each individual. Each individual has a written path covering their needs, hopes, dreams and aspirations. These are reviewed regularly with their keyworker. In addition, the home has a Bluecoats Path, which is the hopes and dreams for the service. This is reviewed annually with staff to analyse what has been achieved and what will be planned for the future. We discussed with the deputy manager the idea of reviewing the home’s aims and objectives as part of the path to enable them to evaluste what has been achieved in line with the aims and objectives. The deputy manager is currently devising a questionnaire to capture the views of relatives (subject to the consent of individuals) on how life at Bluecoats can be improved. The home has in place appropriate policies and procedures relating to health and safety including fire safety, risk assessment and infection control. An annual health and safty audit is undertaken annually by Dimensions head office and the most recent one was November 2007. Bluecoats (18) DS0000011192.V357583.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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Bluecoats (18) DS0000011192.V357583.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 Bluecoats (18) DS0000011192.V357583.R01.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. 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