Inspection on 16/01/08 for CARE Shangton

This inspection was carried out on 16th 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

CARE Shangton 05/11/08

CARE Shangton 15/03/07

CARE Shangton 27/01/06

CARE Shangton 15/06/05

CARE Shangton 21/10/04

CARE Shangton 10/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 CARE Shangton Melton Road Shangton Leicester LE8 0PS Lead Inspector Diane Butler Unannounced Inspection 16 and 17th January 2008 10:00 th CARE Shangton DS0000001656.V355743.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 CARE Shangton DS0000001656.V355743.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. CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service CARE Shangton Address Melton Road Shangton Leicester LE8 0PS 01858 545401 01858 545777 Len.walker@care-ltd.co.uk www.care-ltd.co.uk CARE (Cottage and Rural Enterprises Ltd) 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) Mr Leonard John Walker Care Home 56 Category(ies) of Learning disability (56) registration, with number of places CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Care Shangton are able to admit one named Resident in category LD/PD (dual disability) as agreed in correspondence with the previous registration authority dated 8/4/92 Care Shangton are able to admit a named Service User in category LD/SI (learning disabilities and sensory impairment) subject of variation application number V8014 15th March 2007 Date of last inspection Brief Description of the Service: CARE Shangton is a care home providing personal care and support for up to 56 residents with a learning disability. Accommodation is provided within five cottages and three flats that have been adapted and are staffed according to individual need. There is a lounge, dining room and kitchen available in each of the cottages and flats and all the communal areas provide space in which the residents can spend time together in comfort. Appropriate facilities are available for residents with physical needs such as accessible showers and one of the cottages is wheelchair accessible. Although the home is situated in a rural area, residents attend a variety of community facilities and the organisation provides an excellent variety of meaningful day service activities, supported employment opportunities and access to colleges. The charges for living at the home vary depending on individuals assessed needs and level of support required. Current charges range from £650.00 per week to £1351.16 per week. Details of what is included in the charges can be found in the Service User Guide (a document which provides relevant information about the home), which is given to all residents on arrival at the home. A copy of the latest Inspection report is available at the home, or it can be accessed via the CSCI website: www.csci.org.uk. Further information about the home is available from the registered manager and/or general manager. CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit, which took place over a two day period in January 2008. The registered manager and general manager were on duty at the time of the visit. When undertaking key inspections the Commission for Social Care Inspection (CSCI) focuses upon outcomes for residents and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting five residents and tracking the care they received through looking at their records, speaking with them and discussion with support workers on duty at the time of the visit. Observation was also used to evidence whether care and support needs were being met. A further six residents and two relatives were also spoken with during the visit. Further planning for this visit included checking the service history of the home and the last Inspection report and looking through the AQAA document (Annual Quality Assurance Assessment), which was submitted to the Commission for Social Care Inspection prior to the visit. The AQAA document is the main way that providers inform us of how well their service is delivering good outcomes for the people using it. Surveys were also sent to a selection of residents and their relatives and a selection of support workers to gain their views of CARE Shangton. Seven resident surveys were returned and three support worker surveys were returned. Comments received include: “I enjoy my weekends at Willow bank”. “I like the home very much”. “I do what I want”. “The service offers a safe and secure environment”. “The service encourages people to take responsibility for their own lives”. “The service has very good training facilities”. “We have regular supervisions and team meetings in addition to this”. CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? All complaints are now appropriately logged in the complaints book and a new system for logging incident records is in place to ensure these are logged and actioned. All incidents of possible abuse are now referred to the local safeguarding team for consideration. Improvements to the environmental have been made including a new kitchen in one of the cottages, 5 showers have been replaced and the flooring in those bathrooms have been improved. New flooring in one of the dining rooms has been laid and a continual redecoration plan is in place. The registered manager and general manager are in the process of meeting with all residents and their relatives and/or advocates in order to up date their Person Centred Plans. All house managers are currently completing the Registered Managers Award and both the registered manager and the general manager have completed their Diploma in Management. CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 7 Dementia awareness training has been provided to the support workers working in Ashgrove Cottage. 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. CARE Shangton DS0000001656.V355743.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 CARE Shangton DS0000001656.V355743.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): 1,2,4 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are appropriately assessed before moving into the home to ensure that their needs can be met. EVIDENCE: A comprehensive service user guide is in place. This document, which was reviewed in December 2007, is provided in an easy read format and is given to all residents living at the home. Information within the service user guide includes what CARE aims to do, what services they provide and how much things cost. A residents agreement is included which all residents are required to sign and details of how to complain if someone isn’t happy is also included. Residents spoken with during the visit stated that they had received this information and one resident was able to show their copy to us. A one week assessment is offered to all prospective residents and a ‘getting to know you pack’ is completed before the resident arrives. This document along with an assessment from the resident’s social worker enables the staff to gain a good picture of the resident, what they like to do and the types of support they may require. CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 10 Residents spoken with confirmed that they were able to look around the home and stay for a while before they moved in. Comments received included: “I came and had a look around and came for an assessment and stayed in Cherry Grange Cottage”. “I did a weeks assessment to see if I liked it”. Once living at CARE Shangton the resident’s needs are further assessed and the necessary risk assessments are carried out. CARE Shangton DS0000001656.V355743.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, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are consulted on, and participate in, all aspects of daily life in the home. EVIDENCE: Care plans and person centred plans are in place and evidence of residents being involved in completing these was seen. Plans covered the health, personal and social care needs of the residents and included their likes and dislikes within daily living. Residents living at CARE Shangton are able to make decisions on a daily basis, these include when to get up and when to bathe/shower, what to wear, what to eat and where to eat it, and what activities they wish to complete. CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 12 One resident explained: “Its nice here, you can do what you want, in the evenings they take us to the pub”. A second resident stated: “We can do what we want, we cook for ourselves and get up when we want”. All residents are fully involved in life at the home. Issues that arise are discussed on a daily basis and resident meetings are held regularly. Minutes of the last meeting held on 7th November 2007 were seen. The general manager stated that whenever possible residents would be involved in the recruitment process for new support workers, this was confirmed whilst talking to residents and support workers during the visit. Support workers enable the service users to take responsible risks on a daily basis and risk assessments are in place for all activities undertaken. It was noted that some of these risk assessments hadn’t been reviewed for some time, including some, which had last been reviewed in 2006. This was discussed with the general manager who stated that this would be addressed. Residents are enabled to live an independent life style within the home and support workers support them to meet their individual goals. CARE Shangton DS0000001656.V355743.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 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to live fulfilled and independent life styles. EVIDENCE: Residents are encouraged and supported to attend places of work, local colleges and/or day services provided at CARE Shangton. One resident spoken with explained that they worked at the café in a nearby park and another explained that on Fridays they do voluntary work in town. CARE Shangton day services provide a number of fully equipped workshops where residents can access a wide range of activities. An industrial kitchen enables residents to cook cakes etc, which are supplied to a local café for sale, items such as bird tables, planters, jigsaws and tea light holders are made in the woodwork workshop, rugs, bags and other craft items are created in the CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 14 craft workshop and plants and flowers are grown in the green houses on site. Other activities offered include drama, IT and car maintenance. Residents are also supported to access appropriate community and leisure activities; this includes supporting them to attend college and on shopping trips, horse riding sessions, tennis and swimming at the local leisure centre and going out to pubs and restaurants. Comments received included: “Mondays I do woodwork, Tuesday I do drama, occasionally I go to college on a Wednesday, Thursday morning I am in the gardens and Friday I do voluntary work”. “Weve got lots of drama and activities to do and were going out for a meal on Saturday”. “I go swimming on a Monday and my key worker takes me out on different trips”. Daily routines within the home promote privacy, independence and choice. All residents have keys to their rooms and can choose whether to be alone or join the other residents. They are encouraged and supported to cook for themselves, clean and do their own laundry and support workers ensure privacy by knocking on doors and waiting to be invited in. Residents have a key worker who supports them within the home. Those spoken with said that they knew whom their key worker was and that they helped them if they needed anything. One explained, “My key worker is xxxx I would talk to her if I needed anything”. A healthy balanced diet is offered, the main meal of the day is provided in the main dining area and all other meals are prepared and eaten in the individual cottages. Residents are supported to plan and prepare their own meals and mealtimes are relaxed, flexible and unrushed. Visiting and maintaining contact with family is strongly encouraged. Relatives spoken with during the visit stated that they were made most welcome and were able to visit at any time. One relative explained “It is the most perfect place for our daughter, they have total freedom, the management is very relaxed and we are made most welcome”. CARE Shangton DS0000001656.V355743.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, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are looked after well in respect of their health and personal care. EVIDENCE: Residents are encouraged to be as independent as possible and are supported to care for themselves. For those less able, support and guidance is offered in a sensitive and flexible manner. Care plans and person centred plans (PCPs) are in place to show support workers how the residents prefer to be supported and inform them of the residents individual likes and dislikes around daily living. One resident explained “I have a PCP and do it with xxxx [their key worker]. Daily records show that residents are able to access healthcare services such as Doctors, Opticians and Dentists and the relatives of one resident explained that the house managers and support workers have no hesitation in contacting the doctor if they have any concerns about their daughter. CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 16 With the exception of Ashgrove cottage all residents have their medication stored in lockable cabinets in their own rooms and support workers, who have all received training in the administration of medication, assist them to access their medication at the required times. On checking the records for one resident it was noted that, with the agreement of their GP, support workers were crushing their medication as they were unable to swallow it whole, this was not included in their care plan or risk assessment. This was discussed with the manager who stated that this would be addressed straight the way. In Ashgrove cottage where the residents are less able, the medication is stored centrally in the medication room. On checking the blister packs for two residents it was noted that tablets had been taken from the end of the month, on speaking with the house manager we were informed that this was because the residents had started the medication during the months cycle, for one resident this had been corrected ready for the next months medication cycle though for the second resident this was proving more difficult to address. The house manager explained that he had tried to ask for extra tablets to remedy the problem but the consultant who prescribes the medication will not currently prescribe more than the 84 tablets required for the month, the house manager stated that he is still trying to address the problem. It is recommended that this issue be recorded on the resident’s records to demonstrate what actions are being taken. On checking the medication administration sheets it was noted that not all medication had been signed for when given. This was again discussed with the manager who immediately arranged to have the staff member in question retrained in medication administration. Weekly audits have also been increased to ensure the correct procedures are adhered to. All residents spoken with stated that the support workers treated them with respect and offered support in a relaxed and friendly manner. Comments received included: “The staff are all very good”. “The staff treat us very well”. “The staff are very nice”. CARE Shangton DS0000001656.V355743.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents feel safe and are protected from harm. EVIDENCE: A complaints procedure is in place and a copy is given to all residents and their relatives to ensure that they know how to make a complaint. All residents spoken to on this occasion knew who to talk to if they were worried about something and all support workers were aware of how to support a resident who had a concern. Comments received included: “I would talk to the staff in Willow Bank Cottage if I wasn’t happy”. “I’d tell the staff, I’d talk to xxxx [key worker]. The AQAA (Annual Quality Assurance Assessment) document received prior to this visit stated that four complaints had been received since the last inspection in March 2007. This was confirmed on speaking with the registered manager. Three of the four complaints received regarded the recent decision by CARE to charge residents for transport and the forth was regarding a personality clash between two residents. All complaints received were taken seriously and dealt with appropriately. CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 18 A comprehensive policy on abuse is in place, training in the protection of vulnerable adults is provided during the support workers induction period and both management and support workers were well aware of the actions to take should any form of abuse be suspected. All residents spoken with said that they felt safe living at CARE Shangton. One resident explained, “I feel very safe here”. CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 19 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): 24,25,28,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are provided with a comfortable and homely place to live. EVIDENCE: CARE Shangton provides accommodation for up to 56 residents within five cottages and three flats. Each cottage provides appropriate communal space including a lounge; kitchen and dining room and laundry facilities are available. All bedrooms are single with a lockable door and toilet and shower facilities are close by. A number of improvements have been made since the last inspection and an ongoing re decoration programme is in place. CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 20 The kitchen in Willow Bank Cottage is in the process of being refurbished, five showers have been replaced and the flooring in these bathrooms has been improved. The dining room floor in Willow Bank Cottage has been replaced and a number of new windows have been fitted. The communal areas seen on this occasion were appropriately maintained and decoration and furnishings were of a good standard and presented in a comfortable and homely way, however, it was noted that a number of carpets in Ashgrove Cottage were quite badly stained. The rooms belonging to some of the residents spoken with during the visit were seen. These were clean, appropriately furnished and included their own personal belongings. The enclosed garden to the rear of Ashgrove Cottage has been improved with wide paths and special planting. A number of staff are in the process of completing training in infection control. All service users spoken with were satisfied with the accommodation provided. CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 21 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): 32,33,34,35,36 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents are supported by competent and qualified staff. EVIDENCE: CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 22 A thorough recruitment procedure is in place, application forms are completed, references are collected and a CRB (Criminal Records Bureau) and POVA 1st (Protection of Vulnerable Adults) check are obtained. On checking three support workers files it was evident that all the necessary checks were in place. The registered manager stated that residents are involved in the recruitment of new support workers when ever possible. This was confirmed on speaking with both residents and support workers during the visit. On the day of the visit the managers were interviewing for the post of house manager. The candidates were given a tour of the home by one of the residents and the resident was then asked their opinion of the candidate before a decision to employ was made. All support workers complete a comprehensive induction programme. This involves shadowing an experienced member of staff in the different cottages to enable them to understand the role of the support worker and completing the LDQ (Learning Disability Qualification, formally known as LDAF). On checking the training records it was evident that relevant training had been provided and support workers confirmed that training is always available. Training completed included: Food Hygiene First Aid Moving and Handling Safe handling of medicines. Fire awareness Protection of Vulnerable Adults. Support workers in Ashgrove cottage are currently completing training in dementia awareness and infection control training is also being completed. All support workers spoken with stated that they were satisfied with the level of the training provided, though one support worker felt that their moving and handling training could have been a little more thorough and more equipment such as a turn table who be beneficial. Other comments from support workers included: “The training here is excellent”. “Lines of communication is good, as a team we know how to communicate”. “It’s a fabulous place to work” CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 23 All of the house managers are currently completing their Registered Managers Award. CARE Shangton has the Investors In People Award and is an accredited training centre for NVQ (National Vocational Qualification and LDQ (Learning Disability Qualification). The registered manager and general manager are committed to ensuring that the staff working at the home have the appropriate skills and knowledge required to meet the needs of the residents in their care. Staff meetings and supervision sessions are provided on a regular basis and support workers spoken with during the visit stated that they felt supported by both the house managers and the registered and general manager. CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,42, Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Resident’s benefit from the ethos, leadership and management of the home. EVIDENCE: Both the registered manager and the general manager have many years experience working at CARE Shangton and both have completed their Diploma in Management. A comprehensive quality monitoring system is in place. At the time of the visit the general manager was in the process of reviewing a number of policies and procedures and an outline of future approaches to Quality Assurance was made available to us. CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 25 Residents meetings and staff meetings are held on a regular basis and regular staff supervision sessions are held to enable the registered manager and general manager to gain everyone’s view of the service being provided. The majority of supervisions were up to date though it was noted that one house manager hadn’t had a supervision session since 2006. Policies and procedures for the health, safety and welfare of the residents are in place and all support workers are made aware of these during the induction process. Risk assessments were in place for safe working practices, though it was noted that some had not been reviewed for over a year. The general manager stated that this would be addressed. It was evident during the visit that the residents benefit from the ethos, leadership and management that the registered manager and general manager provide. There was a relaxed and friendly atmosphere throughout the visit and the interactions between support workers and service users were positive, informal and inclusive. Comments received included: “Staff have always got time to listen”. “Excellent manager who has a good rapour with the residents”. “They look after me”. “ There’s always some one to talk too, the manager has an open door policy”. CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 26 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 3 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 2 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 4 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 2 LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 4 4 3 3 X 3 X CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 27 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. 1 2 Refer to Standard YA9 YA20 Good Practice Recommendations The registered person should ensure that any identified risks to the service users are reviewed on a regular basis. The registered person should ensure that all staff complete the medication administration records in line with the organisations policy and procedure. The registered person should ensure that any assistance with medication is recorded in the relevant records. The registered person should ensure that residents are provided with a clean and comfortable place to live 3 YA24 CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 CARE Shangton DS0000001656.V355743.R01.S.doc Version 5.2 Page 29 - 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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