Inspection on 19/09/06 for Cristos

This inspection was carried out on 19th September 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cristos 06/02/06

Cristos 18/05/05

Cristos 25/02/05

Cristos 21/09/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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 Cristos 27 Medina Villas Hove East Sussex BN3 2RN Lead Inspector Jane Jewell Key Unannounced Inspection 19th September 2006 10:00 Cristos DS0000014194.V311099.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 Cristos DS0000014194.V311099.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. Cristos DS0000014194.V311099.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cristos Address 27 Medina Villas Hove East Sussex BN3 2RN 01273 773717 01273 726076 joyskatulla@hotmail.com www.uknursinghomes.org/cristos Mrs Joy L Skatulla 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) Mrs Joy L Skatulla Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Cristos DS0000014194.V311099.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is eleven (11) Service users must be aged forty-five (45) years or over on admission Only service users with learning disabilities may be accommodated Date of last inspection 6th February 2006 Brief Description of the Service: Cristos is a private family owned residential home registered for up to eleven adults with learning disabilities who are over forty-five years on admission. The home is a substantial detached Edwardian house in a residential road, close to the main shopping area of Hove and the seafront. The family have been leasing the building for more than 20 years, with the current family members operating the home since 1982. Resident’s accommodation is presented across four floors. There are six single and two double rooms with one bedroom having ensuite facilities. There is a passenger lift serving floors above ground floor level. Communal space consists of a sitting/dining room, small foyer that also serves as a smoking area and quiet lounge. Access to both the front and rear of the home is via steps and the layout of the homes interior makes it unsuitable for service users who have restricted mobility. The home provides short term and respite placements, subject to availability and day care services are in the main provided by external day care organisations. The homes literature states that it aims to enable people with learning disabilities to have an ordinary life and to provide a high standard of accommodation and care in a single self contained group living unit. The fees for residential care are currently £382 to £431 per week, depending on the services and facilities provided. Extras such as: newspapers, hairdressing, chiropody, transport, toiletries are additional costs. Cristos DS0000014194.V311099.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information contained in this report has been comprised from an unannounced site visit undertaken over five hours and information gathered about the home since the previous inspection. This includes survey questionnaires, discussion with stakeholders involved in resident’s care, records submitted to CSCI, which has included a pre-inspection questionnaire. The site visit was undertaken with Joy Helen Wilson (Deputy Manager). There home. The site visit involved a tour of the records, discussion with staff on duty inspection was to look at the experiences there. Skatulla (Registered Manager) and were eleven residents living at the premises, examination of the homes and residents. The focus of the of life at the home for people living In order that a balanced and thorough view of the home is obtained, this inspection report should be read in conjunction with the previous inspection reports. The Inspector would like to thank the residents, staff and management for their assistance and hospitality during the visit. What the service does well: What has improved since the last inspection? In line with the shortfall in practice noted at the last inspection the home now records concerns and complaints. This helps to ensure that there is a clear account of the actions taken to address the concerns. An additional ensuite bedroom has been built. This has been completed to a good standard with the occupant of the room saying how much they liked their new bedroom. Cristos DS0000014194.V311099.R01.S.doc Version 5.2 Page 6 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. Cristos DS0000014194.V311099.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 Cristos DS0000014194.V311099.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 2 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides both prospective and existing residents, with a good level of information about what services are provided and what to expect when living at the home. Residents are only accommodated if the home is satisfied that they can meet their needs. EVIDENCE: There is a range of well-documented information about the home and the services it provides, this includes a statement of purpose and service user guide which are displayed at the home and given to prospective residents, representatives and other interested parties. Records inspected showed that the home obtains a copy of a care management assessment from the placing authority, and also conducts its own detailed needs assessment. Assessments are often untaken as part of the prospective residents trial visit to the home. This is so their interactions with existing residents can also be assessed. All prospective residents are encouraged to visit the home to help them decide whether they wish to live there permanently. Residents have in the past visited with their care managers with one residents saying “I came with my friend to look at the home”. Cristos DS0000014194.V311099.R01.S.doc Version 5.2 Page 9 The number and type of visits is largely determined by the needs of the individual, for example, from staying for a meal, overnight or weekend stay. The first three months is looked upon as a trial occupancy. Permanent residency is usually subject to a review of care needs with residents, their representatives and care managers where available. The manager confirmed a clear understanding of the categories of care that the home is registered for and the statement of purpose reflected these. Many of the residents have lived at the home for a significant number of years. Residents who have recently moved into the home appear to have settled into life at the home quickly and the residents group presents as a settled close cohesive group. The home continues to demonstrate that it meets the needs of residents who live there. All residents consulted spoke positively about their experiences at the home and there comments included: “nice and quiet home”; “I am very independent”; “do what I want as long as I don’t disturb the others” ; “I like living here as it is near the shops” and “Like all the staff do what we like”. Cristos DS0000014194.V311099.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 judgment has been made using available evidence including a visit to this service. Care plans need to provide clear up to date guidance for staff on the range of residents needs. Residents are encouraged to take reasonable risks as part of an independent lifestyle. The homes services and practices promote independence and choice for residents. EVIDENCE: Four individual plans of care were inspected. These comprised of several documents including basic information, short and long term goals and a plan of care. Comprehensive daily notes are maintained for each resident, which contained detailed information on not only events in resident’s lives but also any changes in their needs and preferences. These changes had not been included in the plan of care. This is necessary in order to provide staff with clear, up to date guidance on residents needs. One care plan requested was not available at the time of the inspection, as it had been mislaid. Cristos DS0000014194.V311099.R01.S.doc Version 5.2 Page 11 All of the residents consulted said they were not interested in the development or review of their care plan. In the main it is the deputy manager who completes and reviews care pans, however staff consulted showed a good understanding of the support needs of residents. None of the residents have an annual review with their placements authority. Three monthly care plan reviews are undertaken by the deputy manager. It was discussed that these reviews should include the transfer of any changes in needs from the daily notes into care plans. The home has a developed system in place for enabling residents to take responsible risks as part of an independent lifestyle. For example core risks faced and posed by residents are assessed and any control measures put into place to help manage or reduce risks. Residents are involved in the daily running of the home to the extent of their personal preference, with many opting to have little to no involvement. Residents do not have unlimited access to the kitchen area, due to health and safety considerations. However, some residents are involved in light household chores if they choose, for example, laying and clearing tables, preparation of snacks. Staff were observed encouraging residents to make an informed decision as to their preferred occupation for that afternoon by discussing the range of choices available to them. Residents said that they are able to buy and choose their own clothes and dress in accordance with their preferences. Staff spoke of supporting residents to choose clothes that were age and weather appropriate. Cristos DS0000014194.V311099.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): 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 access a range of leisure and community facilities in accordance with their individual preferences or needs. The home ensures that suitable arrangements are made for occupation depending upon individual preferences. Resident’s rights to independence and choice are considered by the home. The meals are good offering both choice and variety and catering for special dietary needs. EVIDENCE: Staff showed an understanding of the needs of older residents to have appropriate relaxation time and appropriate activities and occupation. The majority of residents attend day care services for a varying number of weekdays where there is the opportunity to take part in a structured timetable of activities. Cristos DS0000014194.V311099.R01.S.doc Version 5.2 Page 13 On days where residents are based at the home, and for those residents who do not attend day care, staff are guided by the residents in supporting them to spend their time usefully but balance this with resident’s rights to choose their own occupation. The home has connections with two Charitable organisations SPIRAL and MENCAP who organise holidays and social events i.e. dances and BBQ’s. Several residents spoke of visiting these clubs on weekday evenings or events held at the weekend. Several residents went out independently to use local resources such as shops and cafes. Many residents attend the local church either independently or accompanied by staff. Residents spoke of a range of leisure activities they undertake, these were mainly based at the weekends where specific staff are employed to organise. There was a range of equipment suitable for in house occupation including board games, indoor golf, craft, skittles and audio equipment. Several residents spoke of particularly enjoying going shopping and using local cafes at the weekend with staff. The majority of residents have holidays arranged for this year via local clubs that they attend. For current residents, levels of family contact was reported to vary with only a few described as having regularly contact, while for others, contact was very limited. Where there is contact, staff supported residents to maintain links through regular phone calls. A resident spoke about visiting their relative who lives many miles away and who travels independently to see them. A relative said that they felt able to visit at any time and staff supported their relative to phone them each week. Most residents have set times to arise in order to attend their weekday day care services. Other daily routines however, for example going to bed, bathing there is some flexibility. Staff were knowledgeable about the individual routines and preferences of residents and were observed respecting a residents wish to remain in bed. Menus are displayed and residents are asked their preferred choice of meal. Meals are prepared by the care staff on duty, who follow a rolling menu developed by the deputy manager. The menu offered variety and catered for specialist diets. Residents spoke positively about the food provided saying: “Not bad, nice really you get a choice of what you want all staff are good cooks”; “Helen cooks really well”; “good” and “I like the food”. Meals are eaten in a combined lounge dining room where a fold up table is used in order that all residents can eat together. Cristos DS0000014194.V311099.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 20 and 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health care and personal support needs are well met with staff knowledgeable about the individual needs of each resident. Good medication practices are in place, which safeguarded residents and ensured that their medical needs were being addressed. EVIDENCE: The majority of residents do not require direct personal care. Instead, staff provide emotional and practical support. Where residents do need a level of personal care residents confirmed that staff provided the support in ways that promoted their dignity and independence. Resident’s comments on the help they received included “staff help me bath and give me advice if I want” and “I can talk to any of the girls that work here”. Suitable arrangements are in place for meeting the health care needs of residents. Residents spoke of visits to dentists, opticians and chiropodists, either by themselves or with the support from staff. Records showed that there is regular input from health care professionals. Cristos DS0000014194.V311099.R01.S.doc Version 5.2 Page 15 The system for the administration of medication are good with clear arrangements in place to ensure residents medication needs are met. The home has over 20 years experience of supporting older people with learning disabilities. Staff were knowledgeable about the effects of ageing on the residents and showed a good understanding of the specialist needs of older people. Cristos DS0000014194.V311099.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. The home has a complaints system with residents feeling able to air any concerns. There are procedures and practices in place that supports the protection of vulnerable adults. EVIDENCE: There is a written complaints procedure in place for residents, their representative and staff to follow should they be unhappy with any aspects of the service. This is displayed around the home and is contained within the homes literature. No one said that they have ever had cause to raise any concerns but felt confident to approach any staff member if they did. Residents said “I would tell someone if I wasn’t happy”; “I can speak to any staff member and management when I need to”. There are written policies covering adult protection, which identifies different types of abuse, possible indicators of abuse and how to report suspected abuse. Staff undergo adult protection training and those staff consulted were aware of their roles and responsibilities under adult protection guidelines. The manager oversees the finances for all but one resident. Records relating to residents personal monies, provided a clear audit trail of any monies handed over to the resident or spent on their behalf. Various arrangements are in place for the distribution of resident’s allowances, depending on their needs and agreed with the resident. Cristos DS0000014194.V311099.R01.S.doc Version 5.2 Page 17 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): 23 26 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. Residents live in a clean and homely environment with some minor redecoration necessary to ensure a consistently pleasant environment throughout. Bedrooms were found to be comfortable and personalised with furnishing and fittings in good condition. Infection control practices need to be tightened up within the kitchen. EVIDENCE: The home is located near to the main shopping area in Hove and local facilities such as libraries, museums and bus and train services. The owners have leased the building for a significant number of years and are able to make minor structural changes without having to seek permission from the landlord. The home has recently converted the basement flat into an ensuite bedroom. The room has been completed to a high standard with the occupant saying how much they liked their bedroom. This conversion has been the main thrust of the homes property budget for some time, it was discussed that there is now a need to complete minor redecoration and repairs throughout the rest of the building to ensure a consistent environment throughout. Cristos DS0000014194.V311099.R01.S.doc Version 5.2 Page 18 This includes redecorations of lounge, remaining bedrooms and outstanding requirements relating to the laundry areas. The home has been required to complete a plan of redecoration and repair, which includes the timescales for the completion of the works. Shared space consists of a combined lounge dining room and small quiet lounge. The entrance hall is used as the smoking area for staff and residents. Outdoor space consists of rear garden, which is accessed via some steep steps and a small front paved area. Following lengthy negotiations with the landlord a green house, attached to the building, has now been demolished. The manager talked of their plans to convert this area into a small roof garden. This would then provided level access to an outdoor space for residents to enjoy independently. Bedrooms were found to be comfortable and personalised with furnishing and fittings in good condition. All residents said that they liked their bedrooms and their comments included: “ My room is lovely, so is the rest of the home” and “I love my bedroom and the house”. Residents who share a bedroom have done so for a significant number of years and all spoke of how much they liked sharing a room with their friend. Bedroom doors are fitted with locks with some residents choosing to lock their rooms when they are not in use. Several rooms did not have a lockable facility in which residents can store items of importance or valuables. The manager agreed to address this promptly. The home is presented across four floors with a shaft lift provide access above ground level. The home is not registered to offer a service to people with physical disabilities, as access arrangements within the home would make it unsuitable for residents with significantly restricted mobility. Some aids are used to help maintain residents independence these included bath seats and grab rails. A call bell system is fitted throughout the home to enable assistance to be summoned if required. None of the residents consulted said that they have ever had to use it. All areas inspected were observed to be clean with a good standard of hygiene maintained. The use of designated protective clothing is needed for staff when preparing food and when entering into the food preparation area, in accordance with good infection control practices. Cristos DS0000014194.V311099.R01.S.doc Version 5.2 Page 19 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 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The relationship between staff and residents was observed to be close and supportive. Sufficient staff are employed who have the competences and personal qualities to work sensitively and respectfully with residents. Regular practical and specialised training is made available to staff. All of the necessary employment checks must be carried out to ensure residents safety. EVIDENCE: At inspection there were two staff on duty in addition to the manager. Staff felt that this was sufficient number of staff to be able to meet the needs of residents in a timely manner. Staff said that when the need has arisen additional staffing have been obtained. Resident’s consensus was that they felt that they received the support from staff when they needed it. Staff interactions with residents were observed to be relaxed offering encouragement, guidance and appropriate choices. Residents spoke positively about staff and included the following comments: “All the staff treat me alright all the time” “I like all the staff they make me laugh”; “They always support me” “they always help me if I need them” and “I take the mickey out of them they make me laugh”. A relative said that “all the staff seem very nice”. Cristos DS0000014194.V311099.R01.S.doc Version 5.2 Page 20 The majority of staff do not currently hold a National Vocational Qualification (NVQ). But have undertaken a range of mandatory and specialist training necessary to undertake their roles to a competent level. The manager is in the process of applying for a number of staff to start NVQ training. Staff consulted spoke respectfully and professionally regarding residents and demonstrated a good working knowledge of resident’s needs and the needs of older people. Staff said that they are encouraged to only work within the range of their expertise and training and to seek advice from the manager or senior staff if they were unsure of situations. There is traditionally little staff turnover at the home, which helps to provide a stable and secure environment for residents. Recruitment documentation seen for a newly recruited member of staff showed that the applicant completed an application form, underwent an interview and a police check. However only one reference had been obtained prior to them starting work. Although a second reference had been applied for, it had not yet been returned. It has been required that a minimum of two references must be obtained, including where possible from the last employer prior to commencing employment. Cristos DS0000014194.V311099.R01.S.doc Version 5.2 Page 21 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to benefit from a well-established and experienced management team who provide a clear sense of leadership and direction. Health and Safety is promoted and well managed. There is a need to ensure that there is an effective system for reviewing and self-monitoring the services and facilities provided at the home. EVIDENCE: The manager has a significant number of years experience in managing the home and demonstrated in depth knowledge of the daily running of a service for older people who have learning disabilities. They are in the process of undertaking a recognised management qualification. The manager is supported by a deputy manager who has a significant number of years experience in working at the home. All persons consulted spoke positively about the management team and felt that they provided a clear sense of leadership and direction. Cristos DS0000014194.V311099.R01.S.doc Version 5.2 Page 22 There are some mechanisms in place for the manager to obtain feedback on the services of the home and whether it is achieving its aims and objectives. These include: Feedback questionnaires, discussions with residents and staff meetings. It is recommended that this feedback be integrated into a structured quality assurance system, for the home to use in the selfmonitoring and review of its own practices. There are policies and procedures relating to health and safety. Some good practices were in evidence in relation to the management of health and safety. This included regular testing and servicing of fire safety equipment and servicing of gas safety equipment. Cristos DS0000014194.V311099.R01.S.doc Version 5.2 Page 23 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 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 3 27 x 28 2 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 x LIFESTYLES Standard No Score 11 x 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 3 3 x 3 x x 3 x Cristos DS0000014194.V311099.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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. 1 Standard YA24 Regulation 23(2)(d) Requirement Timescale for action 30/11/06 2 YA24 3 YA30 4 YA34 That a plan of re-decoration and repair be developed, which addresses the areas of redecoration and repair identified and includes timescales for their completion. 23(2)b The laundry room ceiling and walls to be repaired and painted. (Made at inspection of 6/2/06 with timescales of 01/04/06 not met). 13(3) That staff wear designated protective clothing when preparing food or entering into the food preparation areas. 19(1)(b)(i) That at least two written Schedule references are obtained prior to 2 (3) a new member of staff commencing employment. 30/11/06 30/10/06 30/10/06 Cristos DS0000014194.V311099.R01.S.doc Version 5.2 Page 25 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 That a system be established and maintained for the self monitoring and review of the quality of the care and services provided at the home. Cristos DS0000014194.V311099.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Cristos DS0000014194.V311099.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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