Inspection on 22/11/05 for Cana

This inspection was carried out on 22nd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cana 23/01/08

Cana 21/09/06

Cana 14/07/05

Cana 14/12/04

Cana 23/06/04

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Insight - Eastchurch

Southfields

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

CARE HOME ADULTS 18-65 Cana Chapel Hill Eythorne Dover Kent CT15 4AY Lead Inspector Chris Randall Announced Inspection 22nd November 2005 09:30 Cana DS0000023371.V250910.R01.S.doc Version 5.0 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 Cana DS0000023371.V250910.R01.S.doc Version 5.0 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. Cana DS0000023371.V250910.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cana Address Chapel Hill Eythorne Dover Kent CT15 4AY 01304 831739 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) L`Arche (Registered Office) Vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Cana DS0000023371.V250910.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14/07/05 Brief Description of the Service: Cana is a home for 5 people with learning disabilities. It is run by L’Arche, a Christian based charity organisation with homes in many countries, and operates as a community with the core members and assistants sharing their home and their lives. The home is located in a large detached property, set back from the road, towards the bottom of Chapel Hill in the village of Eythorne. There is parking on the site for a maximum of 4 cars and additional, on street, parking can be found on Chapel Hill. The home has the benefit of garden space to the front and side of the property. Although the village is fairly isolated it does have the facilities of a village shop, a church, a chapel, and two public houses. Accommodation for core members is provided in five single bedrooms, one on the ground floor and the others at first floor level. Dedicated single room accommodation is also provided for the assistants. Core members and assistants share the communal spaces of lounge/dining room, T.V. lounge, and conservatory/smoking room; they also share the toilet and bathing facilities. The assistants at Cana are usually either students or assistants from other countries who live and work at the home; all speak and have a good understanding of English. Cana DS0000023371.V250910.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection held over 2 days and took 12 hours (8.7 hours in the home plus preparation time). Many of the standards were looked at during the unannounced inspection held earlier in the year and this visit concentrated on checking the requirements and recommendations made on the last report, and inspecting the standards not yet covered this year. The first day consisted of meeting the new acting manager and three of the assistants, checking on the requirements and recommendations made on the last report, inspecting the standards not covered at the unannounced inspection, inspecting various records, and having a tour of the home. The second day gave the opportunity to meet the core members and a further two assistants and join them all for a cup of tea; to observe the interaction between core members and assistants; and also to observe some of the preparation for the evening meal. What the service does well: What has improved since the last inspection? The requirement made on the last report regarding repairs that were needed in one core members bedroom, and to the conservatory to repair water damage have been attended to. In the interest of infection control all hand wash Cana DS0000023371.V250910.R01.S.doc Version 5.0 Page 6 facilities used by assistants have now been provided with liquid soap and paper hand towels. Comprehensive nutritional assessments have now been undertaken for all core members and weights are recorded regularly. The care plans are being totally updated by the new manager and will be reviewed monthly and signed by the service user or their representative. As part of this review of care plans a new system has been set up for recording appointments with health care professionals and the outcomes of these visits. 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. Cana DS0000023371.V250910.R01.S.doc Version 5.0 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 Cana DS0000023371.V250910.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The home are currently not complying with the conditions of their Certificate of Registration. EVIDENCE: All of these standards were inspected earlier in the year and therefore only standard 1 was addressed on this occasion. The statement of purpose and service user guide has been updated to reflect the changes of manager and assistants, and the complaints procedure included is in pictorial form. However the statement of purpose does not accurately reflect the details of the core members currently accommodated. The home is registered for 5 people aged 18 – 65 and currently has one core member who is well above this age. This was mentioned in the last report but no application for variation has yet been received, although once it was pointed out to the new manager an application form for a variation was requested. Although the home is still meeting the needs of this core member and it would be unkind to have to transfer him elsewhere at the present time, the home is committing an offence by not complying with their conditions of registration. A requirement has been made for the home to comply with the conditions on their Certificate of Registration. Cana DS0000023371.V250910.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, & 10 Core members’ needs are clearly documented in their individual care plans, they are actively involved in all aspects of life in the home, and information about them is kept confidential. EVIDENCE: Care plans are currently being updated for all core members. The new layout includes a page ‘about my health’ and a sheet that will be laminated to be used in case of emergency and to take on holidays etc. Also included in the care plans is a needs, objectives, action, comments and review sheet, and risk assessments. A new recording system has been devised to cover all appointments with professionals, doctor, nurse, chiropodist, optician, dentist etc. The care plans are formulated initially from the joint assessments and the homes own assessment and are updated regularly. Updates to care plans are discussed at the monthly team meetings and the key worker discusses any changes thought necessary with the core member.. There are separate daily log/go between books, which the core members take with them when they visit workshops etc. On most days there are 2 entries, one completed in the home and one by the outside facilitators. However there are some days when Cana DS0000023371.V250910.R01.S.doc Version 5.0 Page 10 no entry is shown and a recommendation has been added that an entry should be made in these books at least once a day. Core members are encouraged and supported in their right to make decisions. They have choices in all aspects of their daily lives, when to get up and go to bed, where they want to go, what they want to do, who they want to see, what they want to eat, what to spend their own money on, and what they have in their own bedrooms. There are weekly house meetings where core members have the opportunity to air their views on any topic. One of the core members attends regular L’Arche health and safety meetings as a representative of the home. Any limitations on choice are made in the core members best interests and follow risk assessment. Core members are actively involved in the day-to-day running of the home. They all keep their own rooms clean and tidy with the help of assistants as needed, and all help in the cooking of meals. Some core members take specific responsibility for tasks in the home such as putting out the rubbish, setting the table, emptying the dishwasher, collecting the daily paper, and even undertaking some of the regular monthly checks for health and safety. The home operates an effective confidentiality policy. All confidential information is stored in locked filing cabinets in the office. Records kept are accurate, secure and confidential. Assistants are taught the importance of confidentiality during their induction process. Cana DS0000023371.V250910.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 16, & 17 The core members at Cana have a lifestyle that suits their individual needs, they have opportunities for self development, mix with the local community, and make choices in all aspects of their daily lives. EVIDENCE: Core members needs are looked at during their annual review, and they are involved in making choices and decisions about training needs. Currently none of the core members attend a college course although it is hoped that a place may be available for one core member to attend woodwork in the new year. Core members normally attend various craft or therapy workshops from Monday to Friday weekly, these include such things as candle making, weaving, card making, gardening, and working alongside assistants in the shop. One works in the garden twice a week and because of his skills at potting up and transplanting now trains the new assistants in this skill. Another of the core members is being helped to prepare for supported living and spends one day a week at home helping with the house team cleaning, preparing lunches etc. Core members indicated that they liked gardening, and enjoyed helping with the washing up. Cana DS0000023371.V250910.R01.S.doc Version 5.0 Page 12 Core members are very involved in various activities arranged for the wider community of L’Arche and mix and make friends with core members and assistants from the other L’Arche homes nearby. One of the core members has been involved as a member of L’Arche council for the last year, and has been enabled by Cana to attend the monthly council meetings. Activities extend beyond the boundaries of Cana and L’Arche. Core members are well known in the village and are part of village life. Some of the core members go independently to the local shop, or to church, and one delivers the local community magazine and attended the community supper with the neighbours. 3 of the core members were exhibitors at a recent art exhibition as part of Canterbury Festival. One core member is hoping to join a workshop outside the community involving Makaton and computers. Other activities undertaken by core members include horse riding, visiting the cinema, bowling, and occasional swimming. Core members are encouraged to pursue their own interests and hobbies. There is a television room and one of the core members has his own T.V, video and DVD in the lounge, which he chooses to share with his housemates, everyone asks him before using the equipment. Core members all have a 2 week holiday as part of their contract and are involved in choosing the location. Shortly after the last inspection the whole house went to Lyme Regis for a week and they expressed their satisfaction with this holiday. One assistant said, “it was very good”. Core members supply their own pocket money for holidays, and any holidays taken in addition to the fortnight are at their own expense. Several core members go home for short breaks and 3 of the 5 core members are going home for Christmas, the other 2 will remain with the assistants and a traditional Christmas lunch is planned. Daily routines promote independence, choice and freedom of movement. Staff enter core members bedrooms only with their individual permission, and always knock on the door before entering. Service users all have keys to their own bedrooms. There are mail pockets in the hallway for personal mail and core members are supported in accessing their mail. All of the assistants interact well with the core members and they live together in harmony as part of an extended family. There are no restrictions on where the core members can go within the home, the garden, or the village, other than as agreed in recorded risk assessments. Nobody enters core members and assistants personal bedrooms unless invited. The small conservatory is the only area in which smoking is allowed in the home, although some choose to smoke in the covered area just outside the front door. One core member said “I am going outside for a cigarette”. Each core member takes a turn at cooking the main meal of the day with one of the assistants and they are responsible for choosing the menu for that day. Core members likes and dislikes are recorded in their care plans. Most days Cana DS0000023371.V250910.R01.S.doc Version 5.0 Page 13 the core members have breakfast and evening meal at the home but eat lunch times at the various workshops they attend, apart from weekends. The home holds regular parties to celebrate anything of note, birthdays, anniversaries, Halloween, Easter, Christmas etc. and special food is prepared for these celebrations. Assistants said, “I make Sushi when we have a party”, and “tonight xxx and I are cooking chicken”. Core members said, “my favourite is sausages” “I help cook”, and “I like yogurt”. Nutritional assessments are carried out on each core member and weights are recorded monthly with any significant variation being monitored. Cana DS0000023371.V250910.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, & 21 Core members are supported in maintaining their personal and healthcare needs throughout their lives at Cana. EVIDENCE: The home operates a key worker system and core members and their key workers work together to meet their assessed needs. Independence is encouraged but support is given when necessary in maintaining core members personal hygiene needs. Daily routines are flexible to meet the needs of the core members and take into account their preferences. Core members are supported in accessing health care professionals when needed and a new method of recording appointments which is much clearer and is now completed after each visit, has been introduced since the last inspection. Core members are supported in administering their own medication wherever possible. Core members said, “I have been to the doctor today, I have a headache and feel sick” and “I stayed home yesterday and today as I did not feel well”. The homes policy on aging and death is included in their health and safety policy. The L’Arche community do a lot of training for their assistants on bereavement. If the home were able to cope with terminally ill core members Cana DS0000023371.V250910.R01.S.doc Version 5.0 Page 15 with the support from district nurses and doctors they would do so. If it is necessary for a core member to go into hospital at this time they are supported by the home and also get lots of visits from core members and assistants. The home believes in being very open and honest about death and dying. If the dying core member is being cared for at home an assistant will help to nurse them and sit with them. Their families are welcome at any time and are supported by the L’Arche community. If the core member is in hospital the community will help the family by arranging transport to and from the hospital if needed. Family members who live at a distance can also stay at the L’Arche Canterbury house of care, or sometimes with one of the assistants or managers who live off site. There are clear guidelines available to deal with the sudden death of a core member and support mechanisms for other core members, assistants and family and friends are in place. Cana DS0000023371.V250910.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Core members’ complaints are taken seriously and acted on. EVIDENCE: The home has a clear and concise complaints policy, a copy is displayed in the hallway, and the copy included in the statement of purpose and service user guide is in pictorial form. All complaints are recorded, together with the outcome of the investigation. Core members are all made aware of how to make a complaint, but there have been no complaints lodged since the last inspection. The home also has another book where any small problems can be recorded, the manager checks this book regularly and addresses any problems raised. Cana DS0000023371.V250910.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, & 30 Core members live in a comfortable, safe and homely environment with bedrooms that suit their individual needs. EVIDENCE: The home is clean, comfortable, homely, well maintained, and free from offensive odours. Furnishings and fittings are domestic in character. A housing association owns the building and maintenance issues of the homes structure are their responsibility. The requirements made on the last report regarding the need for the wall of the conservatory to be plastered and the damage caused by water ingress in one core members bedroom to be repaired have been addressed. Since the last inspection new locks have been fitted on all doors, internal and external. One core member said “we have got new locks on our bedrooms”. All of the bedrooms in the home are single rooms whether occupied by core members or assistants. All core members rooms are fitted with a wash basin but there are no en-suite facilities Core members rooms are all individualised with their own choice of furnishings, fittings, and personal belongings, and each core member has a key to their own room. Cana DS0000023371.V250910.R01.S.doc Version 5.0 Page 18 The home has 2 bathrooms, 1 shower room, and 2 separate toilets. The downstairs bathroom has been redecorated since the last inspection. The shared space comprises a large lounge/dining area; a small conservatory where core members can smoke if they wish; a separate T.V./music lounge; a kitchen; a laundry room; and a cellar which is used as a store room and also houses a small pool table. There is an accessible garden area for core members and assistants to enjoy the sunshine and fresh air in the better weather. On the first day of the inspection one of the assistants was playing his guitar and singing in the TV/music lounge. The core members currently living in the home do not require any specialist equipment. There are no core members with specific mobility or visual disabilities. Handrails have recently been fitted in both of the bathrooms. The home is clean and hygienic and since the last inspection liquid soap and paper towels have been provided in all bathrooms in the interests of infection control. Cana DS0000023371.V250910.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, & 36 A dedicated team of properly recruited and appropriately trained assistants cares for core members. EVIDENCE: Assistants who staff Cana are part of the L’Arch community. Some of them are students taking time away from their studies and others are from L’Arche communities in other parts of the world. There has been one change recently where the assistant worked at Cana previously, and one new student from Germany. The assistants live and share their lives with the core members of Cana. All new assistants undergo induction training to TOPPS standards, and all are issued with the CSCC code of conduct. The community are looking into paper free NVQ packages. Currently one assistant has NVQ Level 3, and one has a degree. The home has an effective staff team. A staff meeting is held weekly prior to the house meeting with core members. All assistants speak and understand English and one assistant said, “my English has improved”. All of the assistants have some knowledge of Makaton but this type of communication is only used by two of the core members. There are no assistants under the age of 18 and nobody under 21 is left in charge of the home. One assistant said “I like it here” Cana DS0000023371.V250910.R01.S.doc Version 5.0 Page 20 The recruitment procedures of the home are sound. All new staff have police checks done in their own country before coming to England. POVA checks are done in accordance with policy, and two written references are received prior to employment. Training within the first year of employment includes induction, emergency first aid, NAPPI, moving and handling, basic food hygiene, infection control fire, and adult protection. Other courses undertaken include communication and self expression, enabling choice, Makaton, Ageing and learning disabilities, sexuality and learning disabilities, challenging behaviour, and animating prayers and mealtimes. All assistants have supervision 2 monthly or more often if the need arises, and these sessions are clearly documented. Cana DS0000023371.V250910.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40. 41. 42. & 43 Core members benefit from a home that is run in their best interests, and which has an open and inclusive Ethos. EVIDENCE: The acting manager of the home has only been in post for a few weeks but was formerly manager of another L’Arch home in the area for four years and has a total of 8 years managerial experience. Her application to become Registered Manager is currently being processed. The qualifications held by the acting manager include a diploma in welfare studies and a diploma in early childhood in a European context (post grad). She is currently attending a training the trainers’ course. Other training undertaken includes, Makaton, peaceful intervention, NAPPI, first aid, food hygiene, basic health and safety, fire awareness, communication needs, team building, facilitating skills and creative arts therapy. Although a requirement has been made under standard 37 regarding not accommodating service users who do not fall within the conditions of registration, the current manager has only been in post for such a short while Cana DS0000023371.V250910.R01.S.doc Version 5.0 Page 22 and was unaware of this problem until the inspection. She has already started the process of applying for a variation to rectify the situation. The management approach of the home is open, positive and inclusive in accordance with the homes charter. The acting manager is approachable to both the core members and the assistants, and undertakes care duties in addition to her management responsibility. The home has effective quality assurance strategies in place. The community leader meets delegates bi-monthly. A book for noting problems is situated in the kitchen and it was witnessed that core members are using this facility and their concerns are being addressed. The home holds an annual structured meeting for families. The property is surveyed regularly and any faults are reported and action is taken. A notice of the announced inspection was prominently displayed. It was suggested that once the acting manager is settled in her role, she includes family, friends, and visiting professionals in the homes annual quality assurance questionnaires and sends a copy of the analysis to CSCI The homes policies and procedures are all up to date and relevant. Although these are all reviewed regularly the date of review is not always shown and it was suggested that the review date be noted on all policies. Policies and procedures are readily available to assistants and any changes in procedures are notified to them. Record keeping in the home is good. All confidential records are stored in a locked filing cabinet in the office. Copies of important documents are stored at L’Arche headquarters in a fireproof safe with copies only kept at the home. Core members have access to their own records on request in accordance with the provisions of the Data Protection Act. The acting manager ensures the health, safety and welfare of core members and assistants. Assistants are all trained in moving and handling, fire training (twice a year), first aid, and food hygiene and courses are booked for infection control. All COSHH substances are appropriately stored. Certificates were seen for the testing of boilers, electrical safety, PAT testing etc. All taps are fitted with appropriate valves. Tests are carried out and documented to check for legionella disease. All first floor windows are fitted with restrictors. At present there are no radiator covers but these have been risk assessed as safe for the current user group. The home has a health and safety policy and risk assessments are in place for all working practices. All accidents are properly recorded. The overall management of the service comes under the control of L’Arche which is a registered charity. The home is financially viable with the backing from the L’Arche International. The home has current insurance cover at an appropriate level. Cana DS0000023371.V250910.R01.S.doc Version 5.0 Page 23 Cana DS0000023371.V250910.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 X 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cana Score 3 3 X 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 DS0000023371.V250910.R01.S.doc Version 5.0 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 YA37YA1 Regulation 4(1)(b)(c) Sch1(5) Requirement The home must comply with the category of registration and any conditions as set out on the Registration Certificate for the home, and as shown in their Statement of Purpose. Refer to Regulation 24 CSA 2000. Timescale for action 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations An entry should be made every day in each core members daily log/go between book Cana DS0000023371.V250910.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cana DS0000023371.V250910.R01.S.doc Version 5.0 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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