Inspection on 23/01/08 for Cana

This inspection was carried out on 23rd January 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cana 21/09/06

Cana 22/11/05

Cana 14/07/05

Cana 14/12/04

Cana 23/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Cana Chapel Hill Eythorne Dover Kent CT15 4AY Lead Inspector Christine Grafton Unannounced Inspection 23 January 2008 13:55 23/01/08 13:55 Cana DS0000023371.V357757.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 Cana DS0000023371.V357757.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. Cana DS0000023371.V357757.R01.S.doc Version 5.2 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) canahouse@tiscali.co.uk L`Arche Jane Pedersen Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Cana DS0000023371.V357757.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One Service User over 65 years of age whose date of birth is 09/04/1929. 21st September 2006 Date of last inspection Brief Description of the Service: Cana is home for five people with learning disabilities. It is situated in the village of Eythorne. It is a detached property set back from the road. There is parking on the site for a maximum of four cars and parking is not restricted on the road. Accommodation is provided in five single bedrooms, one on the ground floor and the others at first floor level. There is a lounge/dining room, television lounge and a small conservatory. There is a garden at the front and side of the house. The village has a shop and there is a bus service to Canterbury and Dover. Some of the staff are permanent but others come from many different countries to be part of the community within the home and within the area for a specific period of time. Information about the home, including a copy of the last inspection report will be made available on request. Information provided by L’Arche (Kent) on 5th February 2008 states that the fees are from £650.00 to £916.00 per week. However, this date is near the annual fee review date and there may be an increase from 1st April 2008 in line with inflation. Cana DS0000023371.V357757.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 star. This means that people who use this service experience good quality outcomes. Within the L’Arche community the terms core member and member are used but for the purpose of this report the terms resident and staff are used. This report takes account of information received since the last inspection, including a visit to the home. An unannounced visit took place on 23rd January 2008 between 13.55 hours and 17.55 hours. The visit included talking to the manager, staff and residents, looking at some records and looking round the communal areas of the home. In addition to this, one of the residents agreed to show us their bedroom. Surveys were sent out to all of the residents and their relatives and they all replied. Information sent to us by the manager prior to the visit, in the form of the home’s annual quality assurance assessment, has been used and information from the previous inspection referred to. At the time of the visit there were five residents living at the home. What the service does well: Prospective residents are given clear information about the home in ways that they can understand. This includes a pictorial paper guide and a visual guide that they can watch together with people close to them and staff from the home. Residents each have their own personal care plan. This makes sure that staff know the important things about them, so they can give the right support. Residents are able to make their own decisions about what they want to do. Staff promote their rights and choices. They are helped to manage their own money. Relatives commented in their surveys: “They do well in understanding the residents and encouraging them in the things they enjoy. The staff work well with residents on a one to one basis.” “Real attention is paid to the needs and wishes of the individual residents … boredom is also avoided both in the daytime programme and in the use of free time.” Cana DS0000023371.V357757.R01.S.doc Version 5.2 Page 6 Residents have a say about what goes on in the home. They work together with staff to keep it clean and homely. They help do the cooking. They have opportunities to take part in a variety of activities. They attend workshops, college courses and go out into the community a lot, doing things that they want. They can choose a holiday of their own, plus go on a group holiday each year. A relative commented: “Since coming to live at Cana … (the resident) has come on leaps and bounds. Visits to the theatre and cinema plus 2/3 holidays a year. Visits abroad to Italy, France, Germany, Holland and Ireland.” Residents are able to keep in touch with their families and friends. Staff support them with their personal relationships. Staff spend time with residents and communicate effectively with them. Staff receive the training they need to do what is expected of them. A relative commented: “I think the care and attention they have for residents are excellent.” The home is well-run. The opinions of residents, staff and other people with an interest in the home are actively sought and considered to make sure it gets things right. What has improved since the last inspection? At the last inspection, the home was providing a good service. The four recommendations made have all been acted upon and met. These were to improve the records of food provided and fire safety checks, show how quality is being monitored and complete the external work on the building. The manager has also developed a number of the home’s records to make sure that residents can understand them and be more involved in the planning of their care. For example, the development of residents’ own reference booklets, review records and financial passports. These might include photographs of people, places, activities or objects to help them understand and make choices. The new “What do you think about life in Cana?” form that residents complete has added another way for them to say what they think. Several areas of the home have been redecorated with new carpet and floorcovering making it look attractive and homely. New windows were being installed at the time of the visit and will enhance the appearance of the outside of the building and make sure that the home is light and well ventilated. Cana DS0000023371.V357757.R01.S.doc Version 5.2 Page 7 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. Cana DS0000023371.V357757.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 Cana DS0000023371.V357757.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People moving into the home will be given information about it in a way they can understand. They can be confident that their individual aspirations and needs are assessed and will be met by the home. EVIDENCE: The home provides a very clear service users’ guide, written in simple language, with pictures, so it is easy for residents to understand. The manager is currently working on developing a pictorial service users’ guide on CD-rom. This was seen to include photographs of the L’Arche garden workshop at Barfrestone, the front of the house, the church, the local shop at the top of the road and various areas of the inside of the home. The manager spoke of her plans to add simple written explanations and symbols. Once completed, this information will provide a real insight of what it is like to live at the home and what people should expect upon moving in. The manager described the admission process for a new resident. This includes staff from the home spending time with the prospective resident, going through the written service user guide with them and explaining about Cana DS0000023371.V357757.R01.S.doc Version 5.2 Page 10 the home and house rules. When the CD-rom is complete, the manager and new person will watch the CD-rom together and talk about the various photos, life at Cana and opportunities available to them. No new resident has moved into the home for some time, but records seen at this and previous inspections include detailed assessments that are used to inform the care plans. The manager explained that the initial assessment takes place over a period of time that enables the person to visit the home and other residents’ views to be taken into account. Care management assessments are obtained and used to inform the home’s own assessment. Care plans contain lots of important information that show resident involvement, focusing on their personal aspirations. Cana DS0000023371.V357757.R01.S.doc Version 5.2 Page 11 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from having their own individual care plans that reflect their needs and aspirations, ensuring that they are supported to make their own decisions and choices to lead the lifestyle they want. EVIDENCE: Each resident has an individual care plan written in simple language that is easy to understand and covers all aspects of their life. Care plans include a range of things that are important and relevant to the individual, such as, any particular communication needs they have, any behaviour issues, education, work opportunities, leisure activities, maintaining independence and health. The care plan covers issues relating to equality and diversity and shows how anything identified is addressed. A good example of how the home is supporting a resident in relation to sexuality was seen in one of the records viewed and discussed with the manager. Cana DS0000023371.V357757.R01.S.doc Version 5.2 Page 12 Each care plan is written with the resident who is fully involved in setting their own goals, based upon their hopes for the future. Each resident has their own reference booklet that describes the help they need from staff. This is pictorial, written in simple language, personal to them and gives a real insight of them, their needs and wishes. Residents own and keep these themselves. Residents and staff sign up to the “house rules” that aim to enable all members of the household to live together with consideration for each other. There is an expectation that residents will participate in the daily household chores, as well as their own personal housekeeping tasks. Decisions are made and agreed at the weekly house meetings, when residents are consulted about life in the home and help plan the activities for the following week. Talking with residents and staff provided examples of how residents make decisions about their routines and daily lives. The care plans ensure that staff have the information they need to base decisions and promote rights and choices. Residents and relatives surveys also confirmed this. Residents are supported with the management of their finances. They each have their own building society account. The manager is currently developing financial passports for each resident. These have a list of things that are relevant to the individual, for example: things they need to know about their money, where it comes from, where it is kept, what they need to pay for, how to budget and who helps them look after it. Risk assessments are completed to enable residents to be independent and maintain safety. The management of behaviour risks is well documented. Cana DS0000023371.V357757.R01.S.doc Version 5.2 Page 13 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): 11, 12, 13, 14, 15, 16 & 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can be confident that they will be supported to live fulfilling lifestyles, both within the home and in the wider community. They will know that their personal relationships will be positively encouraged. They will benefit from being offered a healthy diet and a sociable setting for mealtimes. EVIDENCE: Residents can take part in a variety of activities in the wider community. They can choose to attend workshops operated by L’Arche (Kent) or day services provided by other organisations. They are also encouraged and supported to attend college courses to develop their skills and further their education. Activities are arranged that are appropriate to the person’s age, wishes and needs. Where a resident chooses not to attend work, their wishes are discussed as part of the review process and other activities chosen so that they Cana DS0000023371.V357757.R01.S.doc Version 5.2 Page 14 do not become bored. When a resident reaches retirement age they are encouraged to have a more leisurely start in the mornings. Residents spoke about their day activities on their return late afternoon. As well as going to the workshops, where they do such things as gardening or craftwork, they also spoke about other things they do. These include visits to the shops, going to church, swimming, attending social events at the other houses in the L’Arche community and going on bus trips to a variety of different towns in Kent. Their enthusiasm for these events was apparent. Several relatives supported this in comments in their surveys. Contact with families and friends is encouraged and supported. This was observed at first hand when a relative arrived to take a resident out. Everyone welcomed the relative, who was full of praise for the home and the support provided to their loved one. Residents and staff also spoke of having birthday celebrations involving families and friends coming for a meal. Holidays are arranged to suit individual wishes and needs. Last year, residents went on their individual holidays in the summer to places chosen by them, plus they had a group holiday at Easter. This year residents are looking forward to their group holiday at the Isle of Wight during the Easter holiday period. Summer holidays are also being planned. A relative commented positively about this in their survey. A weekly housekeeping plan is on display indicating whose turn it is to help with food preparation and other tasks. Residents have time when they do their own laundry and clean their rooms with support from staff. The plan uses photographs of both residents and staff and one resident is in charge of it. The resident was very proud of this and pleased to talk about who does what. The evening meal is a very social occasion, where residents and staff sit down together round one table in the dining room. Residents’ food likes, dislikes or any special nutritional needs are recorded in their care plans and known to staff. Residents are encouraged to help with meal preparation. Meals are planned each week according to who does the cooking. The staff member will then do the shopping for their meal, involving the resident, and make sure the record of food is kept up to date. This shows a varied and nutritious diet. Cana DS0000023371.V357757.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from being given the personal support that ensures their physical and emotional needs are met. They are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: A new document has been developed for each resident entitled: “What help do I need from my reference person?” The resident helps complete this and it is a very personal record of their hygiene preferences, their abilities and how staff should assist them. Residents’ needs regarding the level of support they require with personal care varies according to their abilities. Discussions with staff confirmed their knowledge of each individual. There is male and female staff in the home and most of the time, a male assists a male and a female assists a female. Observations throughout the visit confirm that residents’ privacy and dignity is respected. Records indicated that health care needs are identified and responded to, with attention from appropriate healthcare professionals. New individual health Cana DS0000023371.V357757.R01.S.doc Version 5.2 Page 16 action plans have been introduced that ensure regular checkups. These show the outcomes of medical appointments and that residents are offered routine health screening. Care plans are regularly reviewed. None of the residents currently manage their own medications. Medications are stored in locked cupboards. Since the last inspection, the home has changed to a monitored dosage system provided by a local pharmacy. The manager stated that all staff receive medication training and the home has written guidelines on all aspects of medication management. The manager has also obtained a handbook on medication for carers of people with learning disabilities that contains some useful information and is available to staff. One resident’s medications were checked together with the record of administration. This showed that medication is properly stored and the administration is well recorded. Cana DS0000023371.V357757.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their views and concerns will be listened to and acted upon and they will be protected from harm by the home’s practices and procedures. EVIDENCE: A pictorial complaints notice is displayed in the entrance hall. A resident pointed this out and explained what it meant. The resident went on to say that they were very happy living at Cana and can talk to any of the staff if they have a worry. The relative spoken to was also aware of it and said they have no complaints about the service, but felt confident that anything raised would be dealt with promptly. They added that they are kept well informed about anything happening in the home. No complaints have been received during the past year. All staff receive training about the use of restraint and one staff member’s ‘NAPPI’ certificate was seen. Evidence was also seen that staff attend courses on abuse and its prevention. A staff member was confident in describing the process to follow if abuse were suspected. The home’s annual quality assurance assessment states that there are procedures in place about what to do if you feel you are a victim of harassment, discrimination, bullying or aggression. These refer to race, sex, age and disability. There is a strong ethos in the home relating to valuing the uniqueness of each individual. Evidence already referred to confirms that diversity needs are well supported. Cana DS0000023371.V357757.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a homely, clean, comfortable and pleasant environment, which is well-maintained and safe. EVIDENCE: A number of improvements have been made to the home since the last inspection. Externally, at the time of the visit, new replacement windows were being installed. Once completed this will greatly enhance not only the appearance of the home, but also resident’s comfort, ensuring that rooms are draft free and well ventilated. Internally, several areas have been redecorated including: hallways, stairs, television room, kitchen, one resident’s bedroom and staff bedrooms. New carpets have been fitted in the television room and dining area and new flooring fitted in one resident’s bedroom. New non-slip flooring has been fitted in the bathrooms, toilet, dining area and hall. Two new refrigerators Cana DS0000023371.V357757.R01.S.doc Version 5.2 Page 19 have also been purchased. All of this benefits residents by making sure that the environment is safe, comfortable, bright and cheerful. On this occasion, one bedroom was seen at the invitation of the resident. This had everything needed to meet the person’s needs and enable them to pursue some of their chosen activities such as drawing and listening to music. Communal areas were seen to be clean and free from any unpleasant odours. The laundry facility meets the needs of residents. Bathrooms and toilets are well equipped with the things needed to maximise independence and control the spread of infection. Liquid soap and paper towels are provided in all these areas, plus the kitchen and laundry. Staff attend training on infection control. Cana DS0000023371.V357757.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from the enthusiastic staff team who work positively with them to improve their quality of life. They are protected by the home’s training programme and recruitment procedures. EVIDENCE: L’Arche (Kent) has a detailed training programme in place. This ensures that all new staff complete a thorough induction programme that equips them to do their job. Each new staff member receives a period of introductory training before they work with residents without direct supervision. They have a personal training plan and undertake ongoing training in a variety of subjects related to their work in Cana. The programme includes national vocational qualifications. The two staff spoken to both praised the training programme and the organisation in general, saying that L’Arche supports and develops its staff. Cana DS0000023371.V357757.R01.S.doc Version 5.2 Page 21 Sampling of staff records indicates a robust recruitment procedure that includes: application forms, references, terms and conditions of employment and criminal records bureau checks. Cana DS0000023371.V357757.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 & 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a home that is well-run and managed in their best interests, promoting and protecting their health, safety and welfare. EVIDENCE: The manager has worked at the home for over two years and is experienced and qualified. She described how she keeps up to date with current good practice, such as belonging to a Good Practice Forum put on by L’Arche that meets every six months. The manager had been undertaking a positive behaviour diploma course at a local university, but has withdrawn for personal reasons. None the less, she was able to demonstrate through discussion, actions and records that she has been putting what she has learnt into practice and sharing her new knowledge with staff for the benefit of the residents. Cana DS0000023371.V357757.R01.S.doc Version 5.2 Page 23 Since the last inspection, the home has improved the way it demonstrates how it takes account of the views of residents and monitors quality. An evaluation form entitled “What do you think about life at Cana?” has been introduced and filled in with each resident. This is in pictorial format, with photos, pictures and symbols. A copy was seen that had been completed by a resident in September 2007. Residents’ involvement in their care planning has been developed by making them easier to understand, with the use of photographs of activities, and/or people. An annual review record was seen that had been completed with pictures and symbols that the resident had chosen and stuck in for them self and the manager had typed up. When the resident was happy with it, a copy was sent to their parents. As well as the weekly house meetings already referred to, a delegation of people who use L’Arche services are invited to a “House Delegates Meeting”, four times a year, when they meet with the director of L’Arche (Kent). They are consulted about any important issues arising in the organisation in general and about their lives at each of the Kent homes. Staff are able to air their views at the weekly staff meetings and via their one to one supervision meetings. All of this ensures that people’s opinions are central to how the home develops and reviews its practice. The home then works towards making sure it gets things right. Information taken from the home’s quality assurance assessment, discussion with the manager and areas of the home seen confirm that it is being maintained appropriately. Staff are trained to ensure safe working practices and a sample of certificates were seen to include: fire safety, first aid, food hygiene and moving and handling. Records of fire safety checks are well kept. Cana DS0000023371.V357757.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 4 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 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 4 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Cana DS0000023371.V357757.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 Cana DS0000023371.V357757.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. Extracts may not be used or reproduced without the express permission of CSCI Cana DS0000023371.V357757.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!