Inspection on 19/05/06 for Church Lane

This inspection was carried out on 19th 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

Church Lane 12/03/08

Church Lane 24/09/07

Church Lane 28/11/05

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Church Lane 21 Church Lane Bearsted Maidstone Kent ME14 4EF Lead Inspector Eamonn Kelly Key Unannounced Inspection 19th May 2006 09:45 Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 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 Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 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. Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Church Lane Address 21 Church Lane Bearsted Maidstone Kent ME14 4EF 01622 730867 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) CareTech Community Services (No.2) Ltd Vacant Care Home 20 Category(ies) of Learning disability (20) registration, with number of places Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 2005 Brief Description of the Service: Church Lane residential home provides residential care and accommodation for up to twenty younger adults. The home is divided into 2 separate units: • • Inglewood (1st and 2nd Floors): Up to 10 residents with varying degrees of learning disabilities who have challenging behaviours. This unit also has a self-contained apartment for 2 service users. Church Lane (Ground Floor): Up to 10 residents with learning disability some of whom have physical disabilities. Each unit has all its own facilities (bedrooms, lounges, kitchen and dining rooms, laundry and storage areas). Care Tech Community Services Ltd owns the home. This organisation owns and operates some 450 residential homes for service users with learning and physical disabilities in the UK. The home is located close to the centre of Bearsted near Maidstone. Local shops, pubs and a church are within walking distance. There is a main line station approximately ¾ mile away and bus services are nearby. The home is a large property, set in its own gardens and provides car parking at the front of the building. Accommodation is over three storeys. There is no passenger lift. Residents with a significant physical disability are accommodated on the ground floor. Twenty-four hour care is provided. Weekly fees are £1200-£2000. Additional costs payable by service users/families or care commissioners are shown in both the Service User’s Guide and personal contract. Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced visit between 09.45am-4.00pm consisted of meeting with most service users and members of staff on duty. No visitors were met on this occasion. Six service users completed a survey form prior to or during the visit. The responses indicated that they were satisfied with the care and support they received at the home. The previous CSCI report requested that a number of issues needed be addressed. The purpose of this report is to indicate if reasonable progress had been achieved in addressing these issues. Over the past 6-8 months, Care Tech Ltd has reviewed its provision of services at Church Lane and following from this a wide number of changes at the home has been made. The principle decision was to have 2 separate registered homes in the premises. Two managers are now in place together with their own staff groups. This is to enable these managers and a separate group of staff to provide care and support services for people with differing levels of support needs. This report concentrates on the care and support in place for service users within both parts of the new home. The previous inspection was at a time when the transition had just begun. Care Tech’s area manager, the managers of Church Lane and Inglewood respectively, provided an overview of the changes that have taken place. Meetings with other members of staff and service users in both units served to give a broad understanding of how service user’s current and changing needs are addressed. What the service does well: The premises are suitable for meeting service user’s needs. Those with physical disabilities are accommodated on the ground floor. People with challenging behaviours live on the first and second floors. As part of this arrangement, two service users live in a self-contained apartment that has its own doorbell. Protocols are in place for enabling service users to visit friends with the 2 premises. Service users in both homes have access to the garden. Service users have an excellent lifestyle. There are a number of advanced communication systems in operation to enable service users and staff to communicate. Their changing needs are kept under review constantly. An example was the way a service user completed a CSCI questionnaire. A “talk Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 6 time” record of this was seen. One response was that some staff “gave more choice than others”. The outcome was that the questionnaire was successfully completed and there was agreement that this issue would be addressed further in the next staff/resident meeting. The programme of activities and individual lifestyle of service users are regularly re-assessed. These reviews take place more frequently if a service user’s disposition indicated the need for review or possible changes to his/her routines or lifestyle. What has improved since the last inspection? The provision of services has been changed so that service users with differing needs are looked after in a separate environment within the premises. Two new managers have been recruited. Their applications to become registered managers were seen at draft stage. New Service User Guides are being prepared for each registered home. These will be fully in line with the order recommended in Care Home Regulations Schedule One and are likely to provide even better information to prospective service users, their supporters and care commissioners. The care plan records for each service user have been updated. In the examples seen, support needs have been identified and the way each need is being met has been identified and recorded. In particular, risks to service users have been highlighted and all staff are aware of specific risks relating to service users. The serious defects in medication storage and administration have been addressed and a new training procedure implemented with advice obtained from a CSCI provider relationship manager. Improvements to the premises have taken place. This includes the building of an external ramp and fencing between a side road and the garden. The premises have been adapted so that each unit has it’s own complete set of facilities including laundries and chemical storage areas. The managers have met recruitment targets set by the organisation. This has led to additional support for the established core staff at the home. It has also led to reduction in the need for agency staff that nevertheless still are available as an additional resource. Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 7 All members of staff now have 1:1 contact with their supervisors that is acknowledged to be helpful in reviewing areas of practice and any need for staff development. The training programme has been supplemented by encouragement for managers to identify areas where additional or specific training and staff development would improve aspects of care and supervision of clients with particular support needs. 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. Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 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 Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 Quality on this outcome area is adequate. This judgement was made using available evidence including a visit to this service. Residents and representatives have access to written information needed in making a decision if the home can best meet their needs. Some potential residents and representatives may not find this information as useful as it could be. Residents have their support needs assessed fully before admission. EVIDENCE: A full assessment is carried out before a new service user is admitted. This includes close examination as to whether the service user’s needs can be met by the home, which unit more suitable and reports/assessments in cooperation with Social Services and advocates including advocacy agencies. Pre-admission written information is helpful to prospective service users and their supporters but it is not as clear as it could be. Accordingly potential service users and their supporters do not have the benefit of straightforward information about each of the current units. The respective managers are working on a draft Service User’s Guide that is based on the order of topics in Care Home Regulations Schedule 1. From information given by the managers, prospective service users/supporters are Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 10 more likely to find this new single document (entitled Service User’s Guide but which includes statement of purpose information) even more useful in making a decision about taking up residence. Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality on this outcome area is good. This judgement was made using available evidence including a visit to this service. Service users are helped to make decisions and choices about their lives. EVIDENCE: Individual care plans “case tracked” indicated that there was up to date information about each service user’s needs and how these and new changing needs are met. The information included advice for staff on how to address common risks faced by service users and those that were identified in individual cases. In meetings with members of staff, the challenges faced by each service user were known in detail by staff. With a new organisation now in place where people with significant physical disabilities are cared for in the ground floor home by a separate staff group, there is increased specialisation in meeting these service user’s support needs. The same benefit for residents extends to “Inglewood” unit. There were a number of examples seen where service users make decisions about their lives with the degree of support needed in each case. Some service Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 12 users discussed how they made decisions and how staff helped them. In other cases, care plan records and observation highlighted how staff gained knowledge of service user’s abilities and preferences and gave support to them. Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16. Quality on this outcome area is excellent. This judgement was made using available evidence including a visit to this service. Service users have the benefit of positive and individual lifestyles that include opportunities for social, educational and recreational experiences. EVIDENCE: Profiles of service users discussed during the visit to the service indicated that they were enabled to achieve personal development, were part of the local community and were assisted in maintaining a range of activities and leisure pursuits. Nine of the ten service users at “Church Lane” unit took part in a music activity with the help of 3/4 members of staff. A similar session involving fewer residents was seen later in the day. All six service users in “Inglewood” returned from various locations under the supervision of staff. Some discussed their experiences with the CSCI visitor. Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 14 Members of staff provided access to individual records that indicated how service users were encouraged to benefit from reflexology, aromatherapy, music & movement, art therapy, and physiotherapy. Some service users are attending college courses including drama. They are assisted with visiting external locations for, as examples, swimming and horse riding. Some service users referred to frequent visits to a social clubs, cinema, and restaurants. A large trampoline with safety nets was bought by a service user’s family who has asked that all service users have the benefit of using it. There were many examples of artwork completed by service users on display at the home. Also, photographs of attendance on many leisure pursuits were made available. Bedrooms reflected to a great extent the interests and leisure activities of service users. Discussion with the managers of both units indicated that continuous efforts are made to communicate with each service user using means appropriate to the disabilities of each. In this way and through close observation, the current success or otherwise of the extent of personal development or ability to benefit from leisure pursuits is assessed and reviewed. This could lead to direct discussion with service users and/or their advocates of changes mutually perceived to be of benefit. Examples of how this communication and observation were seen during the visit to the service. Members of staff receive nvci (non violent crisis intervention) training. This forms part of the home’s procedure for working with people who have support needs that could require experienced and professional responses. The success in maintaining good lifestyles for individuals and helping them to live within a communal setting derives in part from staff skills in monitoring reasons for change in moods or disposition and anticipating outcomes and reactions. Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality on this outcome area is good. This judgement was made using available evidence including a visit to this service. Service users receive good healthcare, personal and social support. This includes the benefit of better medicine administration within the home. EVIDENCE: Service users are registered with one of a number of local GP’s in the area. The previous report stated that problems in getting flu injections for service users because of consent issues have been successfully negotiated. They benefit from support services as outlined the Service User’s Guide. This includes access to district nurses through GP’s, to a pharmaceutical service with revised in-house procedures, to community psychiatric services and to dentists, speech therapists, dietician, opticians and chiropodist. A number of services are accessed by referral through the community learning disability team. In the examples seen in care plan records, staff use a variety of means to support service users each in a unique way and to ensure that their physical and emotional needs are known, reassessed as necessary and addressed. Lifestyles are fully reviewed monthly or more often. Reasons for changes in Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 16 behaviour are discussed. Service users, their personal supporters and advocacy agencies are involved in the process. If additional insights or staff skills are deemed advisable, managers are encouraged to discuss these with the area manager and/or human resource services to obtain them. An example of specialist knowledge needed and received related to the ways of dealing with service user’s sexual behaviours. The home’s medication procedures have been reviewed and changed. This included acting on advice from a CSCI provider relationship manager on the proposed procedure and training process. Each unit has its locked medication cupboard and MAR (medication administration record) sheets and care is taken to administer medicines correctly. A number of instances where errors in administration occurred were notified to the Commission. It was stated that lessons were learned from reflection on these instances. Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality on this outcome area is good. This judgement was made using available evidence including a visit to this service. Service users live in an environment where potential forms of abuse are recognised by staff. Residents and representatives views and concerns are listened to and residents are protected from abuse. EVIDENCE: There is a complaints procedure and staff addresses complaints or concerns. Service users are involved in discussing all issues about their daily lives and reaching forms of consensus. The completion of CSCI surveys by service users was an example seen. A note of how this was negotiated with service users with agreed outcomes is kept. This “talk time” record enables a framework for service user/staff discussions to be adopted. The headings under which topics are discussed, in the example seen, were: 1. 2. 3. 4. 5. 6. 7. 8. “Discussion on your personal space.. Discussion on your home’s communal space.. What do you think about how the home is decorated.. What do you think about the facilities in your home.. Do you like the menus. Are you involved enough.. How do you feel about meal times.. Is your day planned well. Do times suit you for meals, outings etc.. Any other issues you want to discuss..” For some service users direct communication is possible. For others, members of staff use a variety of skills to obtain views or identify attitudes or disposition and employ anticipation. Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 18 Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 30 Quality on this outcome area is good. This judgement was made using available evidence including a visit to this service. The premises are suitable for the care and accommodation of service users. EVIDENCE: All service users have single bedrooms. Some bedrooms have specialist equipment and all are individually furnished and have service user’s personal possessions displayed. Some service users lock their bedroom doors and look after the key. The ground floor accommodates service users with significant physical disabilities. The two units operate as separate premises. Within one of the premises, there is additionally a self-contained apartment for two service users. Both units have their own facilities. Each is individually managed with a group of staff comprising senior support workers and support workers. The needs of each group of service users are different and this organisation is a way of meeting these needs more thoroughly. Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 20 There are sufficient bathroom facilities. There home was well maintained inside and out on the day of the visit to the service. A new ramp has been completed and fencing added between the house and a side road. Communal areas suit the needs of service users, staff and visitors. Service users have the benefit of specialist equipment such as a special bath, a ceiling-track hoist, hospital type beds and specialist beds. Any equipment needed for service users would either be purchased or obtained from a PCT if this was the decision reached during a review of a service user’s health. Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality on this outcome area is good. This judgement was using available evidence including a visit to this service. Service users in both units have the benefit of a framework supplemented by good recruitment procedures that include initial training (induction) and ongoing training and support. EVIDENCE: Support workers fulfil the range of tasks necessary in the view of the organisation to provide a complete service to residents. This included direct care activities with service users inside and outside the premises, cooking and domestic tasks. Members of staff stated that their direct participation in all domestic activities was important because of the intertwining of these general roles with day to day support of service users and their involvement in life at the home. The company has a human resource department that assists managers with all aspects of recruitment and staff development. Agreement has been reached between the company and the CSCI provider relationship manager on general organisation procedures. This includes the way CRB checks are administered and the participation of managers in key HR procedures. Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 22 With the near completion of reorganisation to construct two registered homes within the premises, the area manager and home managers have acted on their review of HR procedures. They stated that they now are able to recruit up to their full allocation of staff hours that have been agreed as necessary in meeting service user’s support needs. These staffing levels have been agreed in relation to the different levels of support needed by service users in each unit. This variation also applies to elements of staff development. Staff in each unit has the benefit of access to NVQ courses and mandatory training. In addition, each manager is encouraged to seek specialist training for staff that meets the needs of their residents. Formal supervision arrangements give each member of staff 1:1 time with their supervisor to discuss their personal progress and aspirations. This includes reaching agreement on accessing suitable training and personal development arrangements. The managers provided examples of how they are now able to seek customised training for staff in each unit. The record of staff training completed and planned indicated that members of staff have access to good opportunities to add to their skills and knowledge. Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 23 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, 40, 42 Quality on this outcome area is good. This judgement was using available evidence including a visit to this service. Residents and their representatives can be confident that their interests are protected through the good organisation of their home where service user’s safety and welfare is promoted. EVIDENCE: Experienced managers are in place for both units (“Inglewood” and “Church Lane”). One unit supports service users with varying degrees of learning disabilities and behaviour patterns. The other supports people with learning disability and physical disabilities. Applications have been made for registration of two separate homes within the premises to enable specialist services to be provided to both service user groups. The managers are undertaking training courses that support their applications as registered managers. The premises are suitable for the care and accommodation of service users. The general training provided together with specialist staff development Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 24 (examples are non-violent interventions, managing challenging behaviours, understanding specific physical disabilities) enable staff to support people who live in the unit agreed at pre-admission stage as best able to address their physical, emotional and personal needs. Service user’s interests and development are promoted through the use of occupational devices that assist them to communicate their views on a variety of levels with staff. The deployment of these devices and skills are supported by the home’s staff development facilities and 1:1 access by each member of staff to their supervisor. The completion by service users of survey returns was one situation seen where this activity was used as a way of involving service users in discussing how they saw their involvement in how their home is run. By invitation, a fire safety officer has carried out a survey of the premises. The recommendations made in the report are being implemented. A priority was to have a fire evacuation procedure tested. Medication procedures have been reviewed and changed with a revised training procedure adopted. Storage of chemicals and working procedures (COSHH) has also been improved with performance indicators now in place to promote safe working practices. A number of improvements to the premises have been carried out in the last few months. A maintenance schedule is in place to keep the premises safe and comfortable. Identified risks to service users are included in each service user’s care plan. This includes identification of risks faced by all service users in a general way and those that are specific to individuals. The area manager and home managers have reviewed the possible limitations of the call bell system. The outcome was that the needs of service users are effectively met and their safety is not being compromised. The home makes good use of the CSCI notification procedure that helps staff to reflect on how service levels could be improved. Also managers and staff of the units are assisted by periodic visits and written reports by a company representative. The financial interests of service users are protected (this judgement being possible from examples of advocacy letters seen) by the work of the company’s resident’s finance administrator, which is also an important facility where the home acts as resident’s appointee in some cases. Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 25 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 3 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 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 x 36 3 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 4 12 3 13 4 14 x 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 3 x 3 x Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 26 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. Refer to Standard Good Practice Recommendations Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Church Lane DS0000065345.V294306.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!