CARE HOME ADULTS 18-65
Charis 31 Mile End Road Mile End London E1 4TP Lead Inspector
Seka Graovac Unannounced Inspection 5th March 2007 12:20 Charis DS0000010294.V331712.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 Charis DS0000010294.V331712.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. Charis DS0000010294.V331712.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Charis Address 31 Mile End Road Mile End London E1 4TP 020 7790 3040 020 7702 8251 charis@thmission.f9.co.uk www.charislondon.org Tower Hamlets Mission 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 Andrew R. Bannell Care Home 8 Category(ies) of Past or present alcohol dependence (8), Past or registration, with number present drug dependence (8) of places Charis DS0000010294.V331712.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 26th December 2005 Brief Description of the Service: Tower Hamlets Mission was established in 1870 by Frederick Charrington, heir to a brewer’s fortune. It was set up as a charity by the Charity Commission in 1938, following his death. Charis opened in 1988. The word Charis means grace in the ancient Greek language. The Registered Provider, Tower Hamlets Mission aims to enable people who suffer from alcohol and/or drug dependency to break the cycle of chronic addiction and rebuild purposeful, stable lives through the provision of high quality, comprehensive residential therapy and rehabilitation. Charis Primary Programme is registered with the Commission for Social Care Inspection for provision of care and support to up to eight males with chronic addiction problems associated with alcohol or/and drug dependency. The Programme is six months long. The fees range is £450 to £500 a week. Charis aims to assist its service users: to maintain abstinence as the foundation for a new life in recovery, to develop a more positive mental and emotional way of life, to develop a positive spirituality, to address any outstanding practical matters that need attention and to develop recreational and social activities in recovery. The Programme uses the Twelve Steps framework embracing the spiritual as well as physical, emotional, mental and social dimensions of a person. Apart from the Primary Programme, Charis provides move on accommodation on site in The Charis Second Stage and The Charis Terrace. The premises are situated in the heart of London’s East End, in a quiet close set back from the Mile End Road. The surroundings are peaceful and contemporary. The central feature of a light well and a courtyard with a small fountain and pool give light, a sense of space and a feeling of peace to the building that houses the Primary Programme. There is a Chapel for prayer and meditation. There are good public transport links and other community facilities within walking distance. The staff team and the management are experienced, skilled and committed to the development of the service, service users and themselves. Charis DS0000010294.V331712.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 lasted approximately five and a half hours. The main aim of the visit was to reassess the service provision in accordance with the National Minimum Standards and the Care Homes Regulations. The inspector spoke individually with two people who were using the service and with another two while they were sitting together in the lounge. She spent most of her time talking with the registered manager, but did see and had short conversations with the other staff who were on duty on that day. She viewed various records kept by the project as required. This included individual service users’ files, staff files, health and safety records, quality assurance documentation, etc. The inspector saw various areas of the Project: kitchen, dining room, therapy room, lounge, staff toilet facilities, offices and chapel. What the service does well:
As at the previous inspections, the Charis continues to meet and exceed the assessed National Minimum Standards and provide an excellent residential rehabilitation service for people recovering from drug/alcohol dependency. The people who used the service described their experience to the inspector only in superlatives: “This place is great”, “Brilliant”, “Wonderful”, “The best, I have ever been in”. This was consistent with the Project’s Annual Satisfaction Survey report. The majority of the residents rated the various aspects of the service as 10 on the scale 1(poor) to 10 (excellent). The lowest average rate for any evaluated aspect was 9.5! The Social Care Managers survey was also very positive (8 being the lowest given rate by any of the participants) and contained the following descriptions of the facilities: “Excellent”, “Absolutely first rate”, “Well managed”, “Peaceful”, etc. One person told the inspector: “Before I came here, I was blind about life. This place is like a miracle. I have rediscovered myself. I am enjoying every single day here and feel so grateful…” He also said that he believed that he would have been dead if it had not been for the Charis. Charis DS0000010294.V331712.R01.S.doc Version 5.2 Page 6 Another person told the inspector that the Charis Primary Programme was “a very professional place… Very spot on the programme… There is no hidden agenda, their main motivation is recovery…” The primacy of recovery process was very much felt and appreciated by everybody the inspector spoke to. One person said: “They are not interested in money, but me.” Another person added how much he felt trusted and how in the previous recovery places he had experienced mistrust and constant put down by staff. Everybody the inspector spoke to expressed how kind, caring and professional all staff were at the Charis Primary Programme and how respected they felt. One person was particularly impressed how respectful of different religious believes, the Project was. This was echoed by another person, as they spoke to the inspector of a Sikh who lived with them in the Charis Primary Programme for a while. The manager and staff emphasised the role of person-led self-awareness process and respect of one’s autonomy in recovery of dependency. Trust, confidence and ever widening internal field of choice aiding freeing of one’s will and healing process were carefully nurtured by the Project. That was done in a structured context of well-thought programme with the clearly defined objectives. One service user told the inspector: “They help different roads open up for you.” The other thing that everybody told the inspector about was food at the Charis Primary Programme. The comments were made that the food was: “Excellent”, “Always fresh and delicious”, “Amazing” and one person said that he never ate so healthily in his life. The management and staff at the Charis were experienced and competent. Many were qualified and committed to professional development as well as further improvement of the service that would assist recovery and personal development of people using it. In addition to having service users’ recovery, based on counselling and caring professional relationship at the heart of the Project, all the records required by the Care Homes Regulations were meticulously kept. The environment was simple, modern, clean, well maintained, secure and safe. Space and light were used to create feelings of peace and beauty throughout the premises. This quite minimalist-design principle was maximised with a great effect in the Project’s octagonal chapel. The inspector left the Project with the warm glow of feeling that she witnessed a place that truly enshrined values of respect of one’s autonomy, human connection and compassionate action. Charis DS0000010294.V331712.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? 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.
Charis DS0000010294.V331712.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 Charis DS0000010294.V331712.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): 2. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The Project used comprehensive assessment tools and recorded the outcomes. EVIDENCE: The inspector viewed individual files for three service users. Each of them contained records of comprehensive assessments that covered the following: alcohol and substance misuse history, psychological, social, spiritual, housing, legal, financial, nutritional, physical health, educational and other needs. Prospective service users met with the manager in order to determine their readiness to engage in such intensive rehabilitation programme at that particular point in their lives. Since the previous inspection, the admission procedure has been amended achieving greater flexibility regarding days of the week when somebody may be admitted to the service. First two weeks of the primary programme were focused on service users’ induction and assessment. Charis DS0000010294.V331712.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The well-structured rehabilitation programme was balanced by staff respect for one’s autonomy, needs and choice. EVIDENCE: Each examined individual file contained an individual personal plan. Weekly evaluation notes were kept. Reviews were held after three months of engagement in the programme. The inspector noted that while the initial personal plans felt quite general, the review notes contained much more indepth information about the person’s needs and their “internal landscape”. The Project is committed to providing the best conditions for the service users to increase their awareness of underlying issues and fully engage in recovery. The weeks two to seven of the programme are focused on Life-stories. The engagement is intense and the process is very fluid. It was evident from speaking to the service users and the staff that the service users’ individual
Charis DS0000010294.V331712.R01.S.doc Version 5.2 Page 11 autonomy and choice were respected at all times. This underlined the whole service provision. The files also contained individual risk assessments. There have been no significant accidents in the home. Some people have left the primary programme prior to its completion. Charis DS0000010294.V331712.R01.S.doc Version 5.2 Page 12 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 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users appreciated the given opportunity to break from the alcohol/ drug dependency and develop healthier lifestyles and more personal freedom. They very much enjoyed food at the Charis Primary Programme. Charis DS0000010294.V331712.R01.S.doc Version 5.2 Page 13 EVIDENCE: Charis is based on a structured programme that facilitates all areas of personal development and considers leisure and recreation to be an important part of a balanced recovery. Day trips chosen by the service users were arranged by the Project on a regular basis. The service users mentioned to the inspector that they enjoyed sea fishing at Dover and going to Greenwich Park. They had Oyster cards to enable them to travel across London. Charis has its own pool table, board games and a small library that includes DVDs. Visiting hours are limited because of the Programme requirements. Visitors book is appropriately kept. Pay phone is available, but mobile phones are not permitted. Information Booklet for Residents’ Visitors was clearly displayed. The videos appropriate for children who might be visiting the service were available. One service user told the inspector that he enjoyed his girl-friend’s visit the previous weekend and was looking forward to spending more time with her the following weekend. The other person told the inspector how in the past his family had “closed the door” on him and how much re-building the relationships with them meant to him. House Routines, Rules and Responsibilities and The Primary Programme Timetable were clearly written in the information available to the service users before committing themselves to the Programme. However, it was evident at the inspection, that the Project was committed to encouraging and developing the service users’ individual responsibilities and independence. The service users had regular meetings with the staff and fully contributed to the Project. The Project also holds daily group therapy meetings and recovery spiritual groups. Individual work includes “Step-work” and counselling sessions with a Key-worker. Service users are also required to attend AA/NA (Alcoholics Anonymous, Narcotics Anonymous) meetings on a regular basis. Breaking with the past and adoption of positive and constructive attitudes towards the self, others and society were main purposes of the Primary Programme. Copies of some important books in the field of addiction were available in Portuguese and Polish to address the service users’ linguistic needs. One service user told the inspector that his English language skills have improved a lot since he came to the Charis and he was looking forward to gaining some professional skills in future. Charis DS0000010294.V331712.R01.S.doc Version 5.2 Page 14 One person was particularly impressed how respectful of different religious believes, the Project was. This was echoed by another person, as they spoke to the inspector of a Sikh who lived with them in the Charis Primary Programme for a while. The service users were very positive about the quality of food at the Charis Primary Programme. The comments were made that the food was: “Excellent”, “Always fresh and delicious”, “Amazing” and one person said that he never ate so healthily in his life. The inspector visited the kitchen that was clean and well organised. All required documentation was appropriately kept. The Project used Safer FoodBetter Business paperwork in accordance with the Food Standards Agency. The menus were displayed and indicated a range of varied meals being on offer. The inspector saw the evidence of the service users being asked about their food preferences and wishes in their individual files. They were also given a weekend food allowance to spend on food of their choice. Service users’ feedback on food was actively sought by the Project. The cook is a qualified nutritionist and some staff commented that she brought the quality of food at the Charis Primary Programme to a different level. The service users told the inspector that in addition to enjoying delicious food, they were very pleased to have the opportunity to learn about the nutritional aspects of food. Charis DS0000010294.V331712.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 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The Charis provides an excellent health, emotional and psychological support to service users in accordance with their changing needs. EVIDENCE: All four service users that the inspector saw and spoke to looked well. No service users needed assistance with physical aspects of personal care at the time of the inspection. The recovery process at the Charis was focused on emotional and psychological support and therapy while maintaining and facilitating individual independence and autonomy. The people who used the service were very positive about the support provided to them at the Charis. They described their experience to the inspector only in superlatives: “This place is great”, “Brilliant”, “Wonderful”, “The best, I have ever been in”. This was consistent with the Project’s Annual Satisfaction Survey report. The majority of the residents rated the various aspects of the service as 10 on the
Charis DS0000010294.V331712.R01.S.doc Version 5.2 Page 16 scale 1(poor) to 10 (excellent). The lowest average rate for any evaluated aspect was 9.5! The Social Care Managers survey was also very positive (8 being the lowest given rate by any of the participants) and contained the following descriptions of the facilities: “Excellent”, “Absolutely first rate”, “Well managed”, “Peaceful”, etc. One person told the inspector: “Before I came here, I was blind about life. This place is like a miracle. I have rediscovered myself. I have learnt here about life…learnt about love. I am enjoying every single day here and feel so grateful…” Another person told the inspector that the Charis Primary Programme was “a very professional place… Very spot on the programme… There is no hidden agenda, their main motivation is recovery…” The manager and staff emphasised the role of person-led self-awareness process and respect of one’s autonomy in recovery of dependency. Trust, confidence and ever widening internal field of choice aiding freeing of one’s will and healing process were carefully nurtured by the Project. That was done in a structured context of well-thought programme with the clearly defined objectives. One service user told the inspector: “They help different roads open up for you.” The service users were registered with a surgery and visited GENERAL Practitioners when it was needed. One service user commented about his appointments with an osteopath and a dentist. The inspector checked the medication records including homely remedies and found them satisfactory. The medicines were appropriately securely stored. Charis DS0000010294.V331712.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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Charis has appropriate policies and processes in place to safeguard service users and their visitors. No incidents of this nature have been reported in the Project. EVIDENCE: The inspector viewed the Project’s policies and procedures for dealing with complaints and allegations of safeguarding nature. They were appropriate in their content. The safeguarding procedure linked with the local council’s safeguarding board and included safeguarding of children who might visit the service. No allegations have been made at the Charis. The Project kept a Complaints-log. No formal complaints have been made since the previous inspection either with the Project or the Commission for Social Care Inspection. Any issues or recommendations for improvement were discussed at the weekly house meetings and these were minuted. The inspection methodology indicated that the Charis was a listening service that responded appropriately to service users’ needs. The management and the staff were committed to a high standard of service provision. Charis DS0000010294.V331712.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 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The environment is modern, clean, well maintained and peaceful. The facilities include a light well with an internal courtyard and a pool with ornamental fish, gardens and a chapel. EVIDENCE: The premises are situated in the heart of London’s East End, in a quiet close set back from the Mile End Road. The surroundings are peaceful and contemporary. The central feature of a light well and a courtyard with a small fountain and pool give light, a sense of space and a feeling of peace to the building that houses the Primary Programme. There is a Chapel for prayer and meditation. The gardens are well maintained with service users’ involvement. Since the previous inspection, the outside of the building has been redecorated, as well as the light-well and the lounge. The therapy room has had a new carpet and the shower-room has been refurbished. A new glasssliding door has been fitted in the dining room providing access to the patio.
Charis DS0000010294.V331712.R01.S.doc Version 5.2 Page 19 The Project has replaced many things including a TV (now LCD) and a pool table. All areas of the Project that the inspector saw were tidy and spotlessly clean. There are good public transport links and other community facilities within walking distance. Charis DS0000010294.V331712.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and trained staff. EVIDENCE: One person told the inspector how in the previous recovery places he had experienced mistrust and constant put down by staff. Everybody the inspector spoke to at the Charis Primary Programme expressed how kind, caring and professional all staff were at this Project. The inspector was told that the team consisted of fourteen staff. Five staff were qualified counsellors and there were four project workers. Other staff were mainly responsible for administration, although the roles were flexible and the team worked well together. The team has recently been strengthened by three new staff members as some staff had left the employment. The new Common Induction Standards were integrated with the Charis Induction Procedure and implemented with these three new staff. The induction involved at least four training days. In
Charis DS0000010294.V331712.R01.S.doc Version 5.2 Page 21 addition to paper-based records and certificates, the training records were linked electronically with Skills for Care data. The inspector noted that the other staff recently attended the training in the areas of working with survivors of childhood sexual abuse, working with people with eating disorders, safeguarding of adults and children, how to tell stories that heal, relations between Islam and Christianity, etc. One staff member was doing “Competencies for Drug and Alcohol Professionals” through the Open University. The project was committed to Training and Development of staff and the plan for 2007 was available. Criminal Record Bureau disclosures for the long-standing staff have been renewed. The inspector saw the originals and signed them off so that they could be destroyed in accordance with the data protection procedures. She also saw recruitment files for three new staff. The recruitment procedure was thorough. The inspector discussed the value of spiritual references versus professional ones with the Registered Manager. The minutes of regular supervision meetings were available and indicated that the staff were appropriately supervised. Charis DS0000010294.V331712.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The Charis Primary Programme is managed in an excellent way that enables recovery from drug/alcohol dependency and facilitates development of individual’s autonomy and free will in a safe therapeutic context. EVIDENCE: The Registered Manager is competent, qualified and experienced. He has Bachelor Degrees in Law and Philosophy/ Theology as well as Diploma in Social Work and Residential Care Manager Award. He was supported by the Charity Secretary, two administrators and the Deputy. The Deputy Manager also had Residential Care Manager award, various counselling qualifications and many years of relevant experience. Charis DS0000010294.V331712.R01.S.doc Version 5.2 Page 23 The Project continues to provide an excellent service that is fully compliant with the National Minimum Standards, Care Homes Regulations and Care Standards Act. The manager has regular meetings with the Tower Hamlets Mission Management Committee as well as residents’ sub-group. The members of the Committee also conduct regular visits to the Project and produce monitoring monthly reports (Regulation 26). The reports are also sent to the Commission for Social Care Inspection on a regular basis. All the operations are periodically reviewed and the identified actions are included in the Project’s Development and Business Planning processes. Satisfaction surveys that include different stakeholders are conducted on a regular basis and the reports on the outcomes are internally published. The Charis is an affiliate member of the Federation of Drug and Alcohol Professional services and also a member of the British safety Council. Health and safety risk assessments were in date as all the other related documentation that the inspector checked during her visit were. These included: Gas certificate, Portable Electrical Appliances Test records, Legionela test and the stair-lift service record. Charis DS0000010294.V331712.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 X 2 4 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 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 4 X 3 X X 3 X Charis DS0000010294.V331712.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 Charis DS0000010294.V331712.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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
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