Inspection on 24/11/06 for Chescombe Lodge

This inspection was carried out on 24th November 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

Chescombe Lodge 08/10/08

Chescombe Lodge 09/02/06

Chescombe Lodge 23/05/05

Chescombe Lodge 15/02/05

Chescombe Lodge 31/08/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Chescombe Lodge Westbury Park Bristol BS6 7JE Lead Inspector Vanessa Carter Key Unannounced Inspection 24th November 2006 09:30 Chescombe Lodge DS0000026531.V301312.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 Chescombe Lodge DS0000026531.V301312.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. Chescombe Lodge DS0000026531.V301312.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chescombe Lodge Address Westbury Park Bristol BS6 7JE 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) 0117 9735197 0117 9706903 The Chescombe Trust Mr Kevin Johnson Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Chescombe Lodge DS0000026531.V301312.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 13 persons aged 18 - 65 years Date of last inspection 9th February 2006 Brief Description of the Service: Chescombe Lodge is operated by the Chescombe Trust and is registered to provide accommodation and personal care for up to 13 persons, aged 18-65 years, in the learning disability category. The home accommodates people with a variety of complex needs, some of whom display challenging behaviour. The aim is to provide a comfortable and homely environment in which individuals can be supported to participate in community living. The home itself is a large building that requires high maintenance and is not entirely suited to its stated purpose. It has spacious grounds and blends in well with the local area. It is close to local facilities and amenities, the Downs, and has ready access to public transport. The cost of placement at the home is between £573 – £1,950.00, the amount being dependent upon each individual persons assessed needs. Additional charges are made for a range of different items and these are detailed in the homes brochure. Information about the home can be obtained from the home manager. Chescombe Lodge DS0000026531.V301312.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over 8 hours on one day. Evidence has also been obtained from a number of other sources, namely: Pre-Inspection Information supplied by the Registered Manager Information supplied by some residents in CSCI survey forms – the majority of the residents do not have the capacity to understand the reasons for the questionnaire Information supplied by relatives in CSCI survey forms A touring of the home and the grounds Talking to the registered manager and acting manager Talking to some of the staff Observations of residents and their interaction with other residents and the staff team Looking at staff and care records Looking at other documentation and policies of the home The overall analysis is that the home is a good place in which to live and to work. Despite the property not being ideal, and being in need of continual maintenance and repair, it has been home for many years for the majority of residents and they are familiar with their surroundings. What the service does well: Residents can be assured that their needs will be met because of the homes thorough assessments procedures. Information about the home is kept up to date. The homes care planning and risk assessment processes ensure that residents are supported to be as independent as possible, and can have a say in the lifestyle they lead. Residents are assisted to follow the lifestyle that they are comfortable with, and are helped to experience new opportunities and develop new skills. Residents receive the help they require with their personal and healthcare needs. Residents are cared for by a well-established staff team who are familiar with their individual care needs, and will therefore look after them well. There are good procedures in place to enable the residents to raise concerns, be listened to and have their concerns acted upon and also to safeguard them from harm. Residents live in a home that is well managed Chescombe Lodge DS0000026531.V301312.R01.S.doc Version 5.2 Page 6 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. Chescombe Lodge DS0000026531.V301312.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 Chescombe Lodge DS0000026531.V301312.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): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that their needs will be met because of the homes thorough assessments procedures. Information about the home is kept up to date despite there currently being no available places for new residents. EVIDENCE: The Statement of Purpose has been updated during the year to reflect changes in the staff compliment. It contains information about what the home has to offer, how a resident would be supported to have a meaningful life, and will enable any prospective resident and their representatives to make an informed choice about living at the home. One resident commented on the CSCI survey form that the home had been chosen for them, by a relative and that information about the home had also been given to them. The home accommodates 13 residents and the majority have lived at Chescombe Lodge since it was opened in 1991. The last resident to take up residency at the home was in 2003. It is therefore not possible to assess the homes admission processes. Chescombe Lodge DS0000026531.V301312.R01.S.doc Version 5.2 Page 9 However, each of the existing residents have had their care needs reviewed on at least a six monthly basis, with the care they are then provided being adjusted accordingly. This evidences that the staff are competent in undertaking full care needs assessments and that the residents will therefore receive the care and support they need. Chescombe Lodge DS0000026531.V301312.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes care planning and risk assessment processes ensure that residents are supported to be as independent as possible, and can have a say in the lifestyle they lead. EVIDENCE: Three care plans were looked at as a means of determining the processes the home go through to look at a residents assessed needs and then say how they are going to meet them. Each person had a very detailed “Individual Service User Plan” that was based on the knowledge acquired by the staff team over a period of time. The plans stated how much help the resident required with specific tasks – this may range from just prompting, to ensure the resident completes a task, through to the exact routines that must be followed to satisfy the resident’s care needs. The plans also recorded those things that might upset a resident – “we as staff should avoid…” Examples included “does not like being talked about” and “does not like to have sentences finished for him”. Chescombe Lodge DS0000026531.V301312.R01.S.doc Version 5.2 Page 11 It is evident that residents are consulted about how their needs are to be met, and where this is appropriate will sign to state their agreement to the care plan. The plans include a list of preferred pastimes and hobbies and likes and dislikes of food. One resident commented on a CSCI survey form that they liked to spend time drawing, or watching TV. Observations made during the inspection visit were that those residents at home were pursuing a number of different activities. Each resident is enabled to make decisions about how they spend their time, however much of their time is spent following well established “rituals and routines”. Some of the residents need to have 1:1 support during daytime hours, in order to manage their own safety and that of the staff and other residents, and to deal with any episodes of sudden challenging behaviour. If residents have the capacity to do so, they are helped to participate in activities in the home. They may help out with their laundry, or keeping their room clean and tidy, or with the household shopping. One resident was observed helping make a cup of tea for all the residents. The homes risk assessment processes will ensure that each resident’s specific needs have been explored and any actions that need to be taken to maintain or enhance safety are identified. Risk assessments were seen around management of a resident’s epilepsy, road safety, trips out in the minibus, for example. Each resident will have a “monthly meeting” with their keyworker. The reports seen covered the following topics - health matters, leisure, special events, life skills progress, incidents and strategies and day service/college/employment issues. This process will ensure that their care plans remain up to date and present a true reflection of their needs. Chescombe Lodge DS0000026531.V301312.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assisted to follow the lifestyle that they are comfortable with, and are helped to experience new opportunities and develop new skills. EVIDENCE: One resident goes to college several times a week and is undertaking “Independence Training”, the aim being that in the future, they may be able to live in a less supported environment. One other resident has said that they want to be able to cook their own meals, and staff confirmed that the staff team will be supporting this individual to achieve this. This resident has aspirations to move on to Supported Living arrangements. Residents are encouraged to maintain contact with their family and the staff team will help in making any of the necessary arrangements. Some residents go and visit, or stay, with their family on a regular basis. Others are assisted to maintain telephone contact. Chescombe Lodge DS0000026531.V301312.R01.S.doc Version 5.2 Page 13 The home has two minibuses meaning that the residents have plenty of opportunity to get out and about, either singularly with staff support, or for home trips. Residents have an annual holiday arranged by Chescombe Lodge, and they are assisted by their keyworker in choosing where they want to go. This year there have been four separate holidays – Centre Parcs, Butlins, a cottage holiday and touring in Devon, and Blackpool were the chosen destinations. Holidays would only be arranged if there was a benefit to the resident – if a change in the residents daily routine caused immense anxiety, this would in no way be considered. Discussion with the manager evidenced that the staff team have a supportive approach in enabling residents to have personal relationships, but will ensure that each party is safeguarded from being harmed. A conversation about the capacity of any resident to consent to such a relationship, evidenced that the home has their best interests at heart but takes seriously, the responsibility they have towards their duty of care. As part of the care planning processes, a list of each residents dietary likes and dislikes is recorded. The main meal may either be served at midday or in the evenings, depending upon the resident’s activities. The staff team ensure that each resident has a healthy diet – they safeguard one resident from eating too much and putting on weight, and another one from not eating an adequate amount. The homes menu plans were not inspected on this visit. Chescombe Lodge DS0000026531.V301312.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive the help they require with their personal and healthcare needs, and medication procedures have been improved and are safer. EVIDENCE: The manager and those staff members spoken to demonstrated a good knowledge of the resident’s specific healthcare and personal needs. Each resident receives a differing level of support depending upon his or her care needs. This may range from being prompted or reminded to meet their own needs of full assistance provided by one or two carers. The residents are registered with a number of different GP’s, plus also have access to dentists, opticians, community learning disability nurses, consultants and psychologists. One GP responded on a CSCI survey form “there seems to be a very good rapport between the residents and carers and the general atmosphere of the place appears to be both appropriately relaxed and very caring towards toward the residents”. One resident’s healthcare professional said “the staff were knowledgeable about the needs of my client and respond in positive ways to their sometimes demanding behaviour”. Chescombe Lodge DS0000026531.V301312.R01.S.doc Version 5.2 Page 15 The homes medication procedures have been improved since the last inspection and are now safer. The home has introduced a checking mechanism after each administration time, so that all the necessary recordings are made. One of the managers has delegated responsibility for the ordering, receipt, storage and disposal of all medications and has good systems in place to aid safe working practices. The home only holds a month’s supply at any one time. The use of PRN medications is kept to a minimum and only used if other strategies have been failed to bring about a calming effect. Chescombe Lodge DS0000026531.V301312.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good procedures in place to enable the residents to raise concerns, be listened to and have their concerns acted upon and also to safeguard them from harm. EVIDENCE: The home has not received any complaints since the last inspection. Each resident has a copy of the homes complaints procedure, in pictorial format, in his or her care file – some of the residents had signed their copy. Observations made during the inspection visit evidenced that the residents are ‘comfortable and at ease’ with the staff team and would be able to raise any concerns. One resident came up to the main offices to talk to the senior staff about a matter of concern to them, and it appears that this is a regular, and welcomed occurrence. One resident commented on the CSCI survey form “Yes” when asked if the staff treat them well and that the carers listen and act on what they say. A relatives/visitors comment card was returned to CSCI from 13 people. Nine of them were aware of the homes complaints procedure, but had not ever had to make a complaint. Of the other four relatives, one relative said that they had reason to raise concerns with the home and the matter had been dealt with satisfactorily. Chescombe Lodge DS0000026531.V301312.R01.S.doc Version 5.2 Page 17 The acting manager demonstrated good awareness of safeguarding adult issues and their role in ensuring that the residents are protected from abuse, harm or neglect. Staff spoken with confirmed that they had training in adult protection and also demonstrated good awareness of issues, and their responsibilities in protecting the residents from harm. The home has clear guidelines for staff to follow when they providing 1:1 support, reminding staff to “ask for help if they find any situation stressful and reminding them of their responsibility to recognise potential areas of conflict”. Chescombe Lodge DS0000026531.V301312.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Chescombe Lodge is a large detached property set in its own grounds, on the edge of the Bristol Downs, in the leafy suburbs of Westbury Park. The home had been operating for 15 years. Originally the home was registered to accommodate up to 16 people between the ages of 18-65 years but this is now reduced to 13. The home is located near to local shops and other amenities and two minibuses are available to travel further a field. The home has level access to the front door – this is not locked during the day therefore those residents who are able to can independently access the gardens. There are no lifts in the home therefore any resident with mobility difficulties can only be accommodated on the ground floor. Chescombe Lodge DS0000026531.V301312.R01.S.doc Version 5.2 Page 19 The home is large and spacious and has sufficient communal space to meet the needs of the residents. There are two large lounges, one large dining room and a large hallway with seating. Throughout the home there is much evidence of environmental damage, caused by episodes of challenging behaviour. Despite there being a continual programme of reparation and redecoration, the home is jaded in appearance and in need of a complete refurbishment. This option is not feasible however and the Trust who manage the home, plan to relocate to more suitable, smaller and homelier premises. All relatives have been informed of these plans however as yet there is no definite schedule for when this will start. One staff member said the planned changes were “frustrating slow”. Each resident has their own bedroom but only one room was seen during this inspection. Previous inspectors have reported that the rooms are appropriately furnished and meet the individual resident’s needs. The bedrooms are situated on each of the three floors. Residents can have a key to their room if this is appropriate and indicated by a risk assessment process. Where required, residents may have an “alarm” fitted to their bedroom doors so that night staff in particular, can be alerted to any nocturnal wanderings. Sufficient toilets and bathrooms are located throughout the home and some equipment is in place to assist the staff in meeting the resident’s needs. The home was generally clean and tidy throughout. The only odour was that of the disinfectant cleaning products. The home has designated domestic support on five days. Chescombe Lodge DS0000026531.V301312.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 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. Residents are cared for by a well established staff team who are familiar with their individual care needs, and will therefore look after them well. EVIDENCE: Each member of staff is provided with a job description meaning that the staff team are clear about their role and responsibilities. The majority of the senior staff team have been employed by the Chescombe Trust for the 15 years of its existence, and are therefore skilled and experienced in meeting the needs of the residents. Staff spoken to during the course of the inspection demonstrated that they are fully knowledgeable about each of the residents and their individual needs. Staff work a two-week rota and any ‘spare shifts’ are either covered by one of the staff team or bank staff. This ensures that residents are cared for by staff who are familiar with their care needs. Observations of staff practice and interaction with the residents demonstrated that they were approachable, and respectful of those who they are looking after. The residents appeared to be at ease with the staff. At those times when residents directed challenging behaviour towards the staff, this was dealt with expertly and “with the minimum of fuss”. The home has strategies in place to safeguard staff who are providing 1:1 support. Chescombe Lodge DS0000026531.V301312.R01.S.doc Version 5.2 Page 21 The registered manager and the three other management staff have each completed the NVQ in Care Level 4 and Registered Managers Award. This is over and above the standard required and the manager explained this is in preparation for the proposed changes in service provision. In addition seven team members have NVQ Level 3 and five have NVQ Level 2. All new staff will complete a comprehensive induction programme upon starting their employment at the home. A number of staff are currently working through their programmes. One of the managers confirmed that each new recruit does three days of training before “working under supervision” with the residents. This ensures that new staff are aware of the homes procedures and what is expected of them. The home provided a summary of all the training undertaken and qualifications of the staff team, evidencing that the staff have undertaken a wide range of appropriate training. Discussion with some of the staff confirmed the summary as being a true account. A training file is kept for each worker and each of the managers display their certificates in their own offices. The home has recruited a number of new support workers and examination of four personnel files evidenced that robust recruitment procedures are followed. Prospective candidates for employment have to complete an application form and attend for interview. The manager said that candidates are introduced to the residents and observations of how they interact are made. Before employment starts two written references, CRB and POVAfirst clearance, is obtained. All staff receive formal supervision at regular intervals, and this was confirmed in discussion with staff members and examination of the homes records. Chescombe Lodge DS0000026531.V301312.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is well managed EVIDENCE: Mr Kevin Johnson remains the Registered Manager of the home however due to the amount of time he is spending devoted to the changes of provision/premises, an “Acting Manager” has been put in place. This person has already achieved the appropriate qualifications and has many years experience in caring for residents with a learning disability and other complex needs. A team of staff including a deputy, assistant manager, care manager, senior support workers and support workers support the acting manager in the running of the home and the delivery of the care service to the residents. Chescombe Lodge DS0000026531.V301312.R01.S.doc Version 5.2 Page 23 Each of these ‘managers’ has a long history of employment at the home and has delegated responsibility for a particular task. The deputy manager organises the training for the team, whilst another person organises recruitment and the staff rota’s. As already stated each resident has a monthly keyworker support meeting. This means that the care they are provided with, remains appropriate to their needs. The home have recently completed a staff survey and the outcomes from this have been discussed in staff workshops. The home had been planning to complete a relative survey when the CSCI comment cards were received – this will be completed at a later date. One of the managers has delegated responsibility for health & safety and maintaining the fire checks. However, each member of staff has responsibility to report any new environmental damage that may have occurred and ensure the continued safety of the residents. “Regulation 26” visits will also include a full environmental check. Any maintenance that is required is completed by tradesman called in on an “as and when basis”. The fire log was looked at. Records showed that the weekly and monthly checks of equipment, emergency lighting and fire alarm system were in order and that staff have been involved in practice fire drills on at least a three monthly basis. This means that residents live in a home that is kept safe Chescombe Lodge DS0000026531.V301312.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 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 4 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Chescombe Lodge DS0000026531.V301312.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 YA39 Good Practice Recommendations Relative questionnaires to be sent out routinely to ensure service satisfaction. Chescombe Lodge DS0000026531.V301312.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Chescombe Lodge DS0000026531.V301312.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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