Inspection on 25/05/06 for Carrow Hill

This inspection was carried out on 25th May 2006.

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

Carrow Hill 03/05/07

Carrow Hill 07/12/05

Carrow Hill 11/05/05

Carrow Hill 20/01/05

Carrow Hill 26/11/04

Carrow Hill 15/12/03

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 Carrow Hill 2-4 Carrow Hill Norwich Norfolk NR1 2AJ Lead Inspector Jenny Rose Unannounced Inspection 25th May 2006 10:15 DS0000027439.V297613.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 DS0000027439.V297613.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. DS0000027439.V297613.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carrow Hill Address 2-4 Carrow Hill Norwich Norfolk NR1 2AJ 01603 632626 01603 663845 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) St Martins Housing Trust Mrs Jacqueline Hursey Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20) of places DS0000027439.V297613.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: Carrow Hill is a registered Care home operated by the St Martins Housing Trust, a local charity working with people who have experienced homelessness often through enduring mental health problems or addiction to drugs and/or alcohol or both. The charity also runs another care home and a number of small group living units. Carrow Hill offers residential accommodation to a maximum of 22 persons. It is situated within easy walking distance of the centre of the city. The building is a former detached period residence situated on a secluded wooded site. All the accommodation (on three floors) is in single rooms with a cluster of two or three sharing bathroom and toilet facilities. The second floor also has shared kitchen facilities which allows it to be used for service users planning to move on to more independent accommodation DS0000027439.V297613.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over seven and half hours. On the day there were sixteen residents living at Carrow Hill House; five residents were seen, three were spoken to, one privately. The manager, Ms Jacqueline Hursey was present at the beginning and the end of the inspection. Five members of staff were spoken to, two privately. A tour of the premises was undertaken and a selection of records and care plans were examined. Preparation had taken place in the CSCI office beforehand; a pre-inspection questionnaire and eight resident surveys had been completed. The views expressed in these surveys are included in the report where appropriate. Further comment cards were left with residents for completion if they wished. During the time of the inspection the manager was holding a training session at another venue with full time members of staff. Two experienced locum staff were on duty until their return before the close of the inspection. What the service does well: What has improved since the last inspection? * Additional funding had been achieved for staff being employed to support some residents in some specific activities. * All the communal areas such as corridors and entrance hallways have been redecorated. DS0000027439.V297613.R01.S.doc Version 5.2 Page 6 * The refreshment area within the dining room has been refurbished. * The manager now has somewhere to see people privately, space for team meetings and a quiet area in which to work. This has been combined with a staff sleep-in area with en-suite bathroom facilities. * The manager is completing the ‘care’ element of the NVQ 4 qualification as set out in the National Minimum Standards document. * Fire records are being appropriately kept. * An aviary has been built in the garden for finches and canaries. 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. DS0000027439.V297613.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000027439.V297613.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The overall quality outcome for these standards is good. There is an appropriate, detailed system in place in order to assess the needs of the residents and relevant information is available for residents. EVIDENCE: Three care plans were examined as part of the case tracking process and each contained detailed admission assessments, as well as care plans and risk assessments involving the residents The manager said that where possible prospective residents are invited to visit and/or an overnight stay and this was confirmed by two residents spoken to who had both undertaken overnight stays, which they said were helpful to them before being admitted into the home. The manager said that 48 hour pre-admission visits give a better picture of prospective residents’ needs and whether the home is able to meet them. This was confirmed by one resident’s comment card. However, the manager also pointed out that in some urgent circumstances preliminary visits were not always possible. A Statement of Purpose and a Service User Guide are in place. Since the last inspection, the manager reported that the home has had more short term residents, for a 28 day diagnostic stay, which may result in a more structured placement elsewhere. DS0000027439.V297613.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 The overall quality outcome for these standards is good. Care plans show goals set by residents with staff. Residents are involved as far as possible with decision making in the home and have opportunities to gain independent life skills within a framework of risk assessment. EVIDENCE: The residents spoken to and the care plans examined showed evidence that identification of goals was taking place by staff supporting residents to do this. There were records of progress in such areas as modifying behaviour, including consumption of alcohol and substance abuse, money management, all within a framework of risk taking and risk assessments relating to harm reduction, aggression or exploitation/abuse by others. It was also evident from discussion with the manager, the staff team and residents, as well as from the care plans that the residents at Carrow Hill have diverse and complex needs. One resident spoken to confirmed that together with his link worker that he had made progress in several areas since being in the home. He also spoke of the involvement of other agencies such as the Community Psychiatric Nurse DS0000027439.V297613.R01.S.doc Version 5.2 Page 10 and other healthcare professionals. Reviews take place regularly, including those with social workers, which were confirmed by another resident. Residents’ meetings are held monthly and the Minutes displayed on the notice board in the dining room. There is a food comments book and suggestions box for comments from residents and the quality assurance scheme is dealt with elsewhere in this report. One resident is supported in keeping a personal diary of his medication and significant events to assist with memory difficulties. Another does his own cooking and is supported by staff in his attempt to give up smoking. Residents’ goals are designed to minimise harmful behaviours, which one resident described as finding rather restrictive, although understanding the basis for it. This was also confirmed by one comment card regarding the money plan and alcohol plan he was on; reducing the risk of self-harm therefore depends on the degree of compliance by the residents themselves. The philosophy in the home was explained by the manager as undergoing a change, inasmuch as people were being encouraged to move on to more independent living and this was confirmed by staff and one resident spoken to. At the same time, the manager is reviewing the differing needs of residents passing through the home, who in the main are of a younger age group and presenting more challenging behaviour. DS0000027439.V297613.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 The overall quality outcome for these standards is good. Residents are supported by staff to take part in culturally appropriate activities, are part of the local community and can maintain family and other relationships as part of an individual care plan. The food is good and varied and residents are encouraged to develop cooking and other independent living skills, as well as shopping, if appropriate. EVIDENCE: “My life’s getting better….an improvement” was the comment of one resident. He described being able to keep fit, go swimming and awaiting the membership of a gym, as well as resuming an interest in playing the guitar. This resident also said that he had recently resumed contact with his family with the support of the home and the Community Psychiatric Nurse. Another is being supported by his link worker to find a member of his family through the Salvation Army and another resident spoke of his regular visits to see a relative. DS0000027439.V297613.R01.S.doc Version 5.2 Page 12 The home is situated in a secluded situation within easy walking distance of the city centre and near local shops. One resident was going to the Post Office to post mail for the home and staff support residents on an individual basis with shopping trips, and resolving benefits and related problems of previous homelessness. Staff accompany residents to the museum or for a coffee in the city and to literacy and numeracy classes, if appropriate. One member of staff has a special interest in gardening and there is a set day for gardening for those residents who wish to participate. At the time of the inspection vegetables had been sown and composting was in progress. There is an aviary within the garden inhabited by finches and canaries, which residents help with if they wish. Residents are able to participate in various interests including bowling, visits to a pub, DVD’s and videos. Carrow Hill shares a people carrier with St Martin’s House and also have the facility to use the Trust’s holiday home on the coast. A member of staff described that the resident, for whom he is the link worker, attends a Day Centre three days a week, for which he is picked up in a taxi. The manager described letters being written to residents asking if they would take part in cleaning tasks in the home and clearing the tables in the dining room, as well as helping with an Open Day in the home which is planned for the next few weeks. This was confirmed by two residents spoken to. Two residents spoke of being responsible for their own laundry and one confirmed that he had an allowance for food and was accompanied on shopping trips for the ingredients for the menu, which he prepared himself in the kitchen on the second floor. The staff were observed on the day of respecting residents’ privacy, by knocking on bedroom doors, and another resident described how he is particular about locking his bedroom door. The manager spoke of the philosophy of the home as attempting to keep a balance between residents’ rights and responsibilities. Residents were encouraged to contribute towards their rent at the home and aggressive or inappropriate behaviours were dealt with by a system of warnings, which was set out for residents on their admission to the home and which residents sign. The chef on the day was spoken to and she said that residents participate in cooking sessions, but she was also well aware of the likes and dislikes of the residents, who were able to tell her directly or make comments in the book located in the dining room. The residents spoken to were satisfied with the food and the variety offered. They are able to make hot or cold drinks whenever they wish, in the refurbished area in the dining room, and meals are saved or eater at a later time on request. Fresh fruit, biscuits or cakes are available 24 hours. The chef, who has a catering qualification, expressed an interest in training in other aspects of work in the home. DS0000027439.V297613.R01.S.doc Version 5.2 Page 13 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): 18,19,20 The overall quality outcome for these standards is good. Residents are able to discuss their personal and health care according to their needs with staff, which is recorded in their care plans according to their preferences. Their healthcare needs are met to the extent that residents choose to comply with treatment plans. Medication is appropriately stored and records are up to date. EVIDENCE: Generally speaking, residents are very able and require little help with personal care. Each resident has a link worker who encourages and supports residents in achieving their identified goals. One member of staff described reviewing the care plans for two residents, supporting with money management, every day checking clothes and the general welfare of the residents. Supporting residents to look after their rooms, with hygiene and helping one resident buy a TV for his room. With additional funding he was able to accompany one resident on outings to the museum or into the city for a coffee. From care plans and speaking with one particular resident it was evident that specialist health care is available if needed from numerous agencies, including consultants for gastro and pulmonary problems, alcohol support and substance DS0000027439.V297613.R01.S.doc Version 5.2 Page 14 misuse support services, as well as psychiatric and counselling services. From the care plan and speaking to one resident, bereavement counselling had been given, following the death of a relative. Alternative therapies, such as reflexology were also offered if appropriate. The residents’ surveys received stated that residents were happy with the care they received in the home. “….I am very happy here at Carrow Hill”…was a comment from one resident. The administration of medication from a secure cabinet was observed. All staff undertake Boots training in the administration of medication and no controlled drugs were being kept on the day of the inspection. The daily administration sheets were examined and were up to date. The experienced locum member of staff on duty that day had previously worked full time in the home and for the Trust for sixteen years. She explained that some medication was issued from the hospital, but most medication was contained in a Nomad system. The manager reported that the member of staff overseeing medication for the home was soon to have a planned meeting with the Health Centre, who, the manager reported, are very supportive of the residents. No one in the home was self-medicating. If this stage is reached, many residents would then be moving towards rehabilitation wherever possible in other establishments within the Trust, or living independently in the community. DS0000027439.V297613.R01.S.doc Version 5.2 Page 15 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): 22,23 The overall quality outcome for these standards is good. Residents are aware of the complaints procedure and there are processes in place to protect residents from abuse and to minimise self-neglect and selfharm. EVIDENCE: There had been no complaints received in the CSCI office since the last inspection. All the residents’ surveys and two residents spoken to confirmed that they knew to whom to complain should there be a need. Complaints were taken seriously and responses logged. There had been one complaint since the last inspection and there was a discussion with the manager about how this was dealt with. There are whistle blowing and adult protection policies in place and the Trust provides training for staff on adult protection issues. One member of staff spoken to said that he was in the process of training in the protection of vulnerable adults. DS0000027439.V297613.R01.S.doc Version 5.2 Page 16 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): 24,30 The overall quality outcome for these standards is good. The siting of the home provides residents with opportunities to make use of nearby facilities in the community, at the same time as allowing some seclusion, in addition to the privacy of their own rooms. All areas seen were clean and free from hazards. EVIDENCE: The home is in a building of local historical interest and as stated elsewhere in the report is situated near local shops, as well as within walking distance of most major community facilities available. There is a garden, with which residents can help if they wish. All the recommendations in the previous report have been carried out. There has been considerable redecoration, especially in corridors and hallways. The manager now has an office, which is spacious enough for team meetings, as well as providing a quiet working area and space for private conversation. This office doubles as the sleep-in room, now with pleasant en-suite facilities for staff. The original office space, still used by staff and for storing medication, records, money and other items, is very small, as well as being very busy, DS0000027439.V297613.R01.S.doc Version 5.2 Page 17 particularly at certain times of day, although there is a little more space now that the manager has a separate office. Several residents allowed access to their bedrooms, which were seen to be personalised with music equipment, televisions and furniture if they wish. The manager reported that there are plans for new furniture in residents’ rooms and where possible residents will be encouraged to buy their own, especially chairs. One comment from a resident’s survey was, “I am happy here, I have a nice room”. Staff were observed knocking on residents’ doors and did not enter, if not invited. There is a choice of sitting areas and a large dining room with a refurbished refreshment area where residents can make drinks at any time. As stated elsewhere residents are encouraged to clean their own rooms and to help in the communal areas and the home was clean on the day of the inspection. DS0000027439.V297613.R01.S.doc Version 5.2 Page 18 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): 32,34,35 The overall quality outcome for these standards is good. Although there has been some improvement in staffing levels, more flexibility needs to be considered, based on the changing needs of the resident group accommodated. Residents benefit from well supported and trained staff. EVIDENCE: As at the last inspection, there are a minimum of staff on duty during the day and night. During the week the manager is also present. Two staff have always been viewed as a minimum, but three staff would be more appropriate, especially at times when member of staff is out with a resident. There should also be the contingency for additional staff when specific challenging behaviours are posed for staff to cope with. The recommendation from the last inspection has in part been dealt with by the employment of locums, the three members more usually employed in the home are experienced seniors, who have worked in the Trust for many years, thus helping to ensure consistency of care. In addition, it may also be that staff who work for the Trust may cover shifts on other sites. The manager reported that additional funding has been obtained for 18 hours per week, divided between three residents, for accompanying them to specific DS0000027439.V297613.R01.S.doc Version 5.2 Page 19 activities relevant to their care needs. However, there still remains the issue of incidences of challenging behaviours when there is a need for more staff and there is therefore a recommendation that staffing levels should continue to be reviewed to ensure that specific situations can be responded to and be available to accompany individuals to activities meeting specific needs. In addition, one member of staff raised the issue of the gender balance of staff during the day, which was confirmed by the manager. At present there are fifteen male residents and only one full-time and one part-time male member of the day staff, although the ratio is larger amongst the night staff. There is therefore a recommendation that consideration be given to best practice being followed by having, wherever possible, a better gender balance in the day staff. A member of staff described the induction and foundation training and numerous courses he had attended since joining the staff three years ago, including Promoting Independence, Handling Aggression, Dual Diagnosis, Blood borne viruses and NVQIII (naming only a few). This member of staff also commented enthusiastically that the organisation and management were approachable and that there was a good staff team, who worked well with the residents, especially in supporting some to move to more independent living situations. The manager was holding a training session with full-time members of staff the day of the inspection on such aspects as Rights and Responsibilities, House Rules, Key working, Care Planning with handouts on Challenging Behaviour and Personality Disorder. There is a full training profile for each member of staff and NVQ and equivalent courses are also available. Some members of staff are opting for the Diploma in Health and Social Care and Community Mental Health training, which is more geared to the needs of the residents at Carrow Hill. From speaking to staff there was a clear recognition of responsibilities and roles amongst members and they all spoke of a good staff team, not only within the home, but also amongst the larger organisation. Staff supervision takes place on a regular basis, although from anecdotal evidence there is also much informal supervision. Staff described good handover periods at the end of shifts and a longer team meeting weekly on Mondays. From the examination of three staff files it was evident that they contained the required information such as written references and Criminal Records Bureau checks. From speaking to residents, from observation and the resident’s surveys, there is evidence that residents feel supported by the staff team. DS0000027439.V297613.R01.S.doc Version 5.2 Page 20 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): 37,39,42 The overall quality outcome for these standards is good. The manager is completing the care component of NVQ4. There is a quality assurance process in place, but the proposed development of the review form seeking residents’ views will further ensure that these underpin developments by the home. The health, safety and welfare of residents is protected as far as possible by the keeping of proper records and checks. EVIDENCE: As recommended at the last inspection, the manager confirmed that she is in the process of completing the care component of the NVQ4 qualification. She already has much experience and has recently completed a course in Dual Diagnosis and hopes to undertake the Community Mental Health Course. The manager also described the Trust as having computerised the organisation, making communication easier, as well as ‘staff sharing’ between DS0000027439.V297613.R01.S.doc Version 5.2 Page 21 managers in the different establishments within the organisation. In addition, the managers meet and share information once a month, which is minuted. Residents’ views are sought by various means as mentioned elsewhere in the report, but the manager said the admissions form was currently being revised with a section for a survey of the service to be carried out at each review. Residents’ surveys and residents spoken to confirm that they felt their views were listened to. The quality assurance process includes monthly visits in line with Regulation 26. The manager has also prepared a Business Plan for 2006 and an analysis of the resident group’s changed needs for the year December 04 to December 05. Various health and safety records were examined, boiler servicing and water temperatures. The fire record was up to date and tested weekly, last tested on 22 May 2006. Chubb would be carrying out a full fire risk assessment on all the Trust’s buildings and evidence was seen of a visit to the home on 30.3.06 for additional firebreaks to be installed. Accidents were seen to be appropriately recorded. Also, following a recent incident, a review of the procedures for keeping and distributing petty cash had taken place and a different system instituted. DS0000027439.V297613.R01.S.doc Version 5.2 Page 22 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 X 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 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X DS0000027439.V297613.R01.S.doc Version 5.2 Page 23 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. Refer to Standard YA33 Good Practice Recommendations It is recommended that staffing at particular times continue to be reviewed to ensure staff can respond to situations and also be available to accompany individual residents without leaving the house without enough staff cover. It is recommended that a better gender balance amongst day staff be given some consideration and review when appropriate. 2. YA33 DS0000027439.V297613.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 DS0000027439.V297613.R01.S.doc Version 5.2 Page 25 - 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. 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