Inspection on 12/09/07 for Croftlands

This inspection was carried out on 12th September 2007.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Croftlands 28/08/06

Croftlands 10/02/06

Croftlands 22/07/05

Croftlands 10/03/05

Croftlands 15/04/04

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

CARE HOME ADULTS 18-65 Croftlands 41 Durranhill Road Carlisle Cumbria CA1 2SW Lead Inspector Liz Kelley Unannounced Inspection 12 September 2007 10:00 th Croftlands DS0000022572.V344159.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 Croftlands DS0000022572.V344159.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. Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Croftlands Address 41 Durranhill Road Carlisle Cumbria CA1 2SW 01228 524296 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) The Croftlands Trust Mrs Barbara Johanna Dupuy Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. To accommodate nine people in the category of Mental Disorder (9MD). To accommodate one named person in the category MD(E) (1 MD(E) Date of last inspection 28th August 2006 Brief Description of the Service: Croftlands accommodates up to 10 people who have difficulties in maintaining aspects of their mental health. The intention of the service is that people can live in the home for up to three years. The goal is to help service users move onto other accommodation where they can live as independently as possible. The premises is a large detached three-storey Victorian style property, which has been modernised and converted for its current usage. The house is situated in a suburb of Carlisle and stands in its own walled gardens with a driveway leading up to the entrance. Each service user has an individual bedroom with wash hand basin, and each floor has a bathroom or shower room. There are two lounges and two kitchens on the ground floor. The home has a zero tolerance on illegal drugs. A shelter is provided in the garden for smokers. An office, staff room and staff sleep-in room is also provided. Croftlands is run by The Croftlands Trust; this is a non-profit making organisation, which runs a number of residential and community based services in the county for people with mental heath problems. Locally the home is also known as Durranhill . A Service Users Guide is available for prospective residents, with details of how to get the latest Inspection report. Placements and referrals are funded and managed via Mental Health NHS Trust. Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an inspection where all the key areas of the National Minimum Standards were checked. People were spoken to and they gave their opinions regarding the service and care to the inspector. An important new addition to this inspection was the use of a person called an expert by experience, who spent time with people individually and gained valuable insights on what it was like living in the home. These comments, and the observations made by the inspector and expert by experience, have informed the judgements made in this report. An ‘expert by experience’ is a person who, because of their shared experience of using services visits a service with an inspector to help get a picture of what it is like to live in or use the service. The inspector also: • Received questionnaires from professionals and other people working with the home • Interviewed the manager and staff • Visited the home, which included examining files and paperwork • Received a self-assessment report/questionnaire from the manager. What the service does well: Croftlands is playing a key role in supporting individuals to develop and move on. One person said to the expert by experience their mental health was “one hundred per cent improved and felt that he was receiving excellent physical, emotional, social, and spiritual (personal) support. When asked, he gave the home an A* rating. In other words, he judged Croftlands to be “an excellent place to be”. He, too, was quite clear as to why he was in the home, ie, his goal being independent living in, perhaps, in a year’s time…. He sees his key worker (mentor) every week for an hour on a one-to-one basis.” The Expert by Experience also summed up well the strengths of the staff team. “I was extremely impressed with the standard of people who are the formal care staff in Croftlands and was given the opportunity to talk to them at length during the course of my visit. The Manager of Croftlands is obviously deeply committed to helping both residents and the young members of staff to fulfil their purpose in life. Between them, they have a common goal in that they are helping people move on towards independent living in sheltered accommodation or, in some cases, to take their place as equal and responsible citizens” Croftlands DS0000022572.V344159.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. The summary of this inspection report can be made available in other formats on request. Croftlands DS0000022572.V344159.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 Croftlands DS0000022572.V344159.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There has been significant improvement in helping people to make informed choices through better clarity of the aims of the home and the service people can expect to receive. EVIDENCE: At the last inspection the organisation was recommended to review the homes aims and Statement Of Purpose document in light of changing referrals and changes in mental health provision in the area. The home was divided between those who consider Croftlands their home and have lived there several years and those who are only likely to stay for several months. This was causing frictions between service users and a conflict in approach for staff between crisis intervention and those who were long-term residents. Since then Croftlands Management Committee has agreed a revised mission statement for the Home and 10 statements of values. The organisation has set up meetings with the Integrated Team (Health and Social Services) and commissioners of the service to review the homes purpose in light of developments in Mental Health provision. Quarterly meetings are now held to discuss proposed referrals and to review each person’s stay at Croftlands. Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 Page 9 Each person now referred to the service has a comprehensive assessment carried out jointly between the person, the referrer and the manager of the home. This includes the expected outcome and approximate length of a placement, and a plan in the event of a placement failing. This has led to much clearer goals, and given each person a clear direction of the purpose of their stay. People are no longer left to drift, and even those who have lived in the home for several years are now considering alternatives to a residential care home, such as more independent living in the community. Due to these changes the manager needs to up-date the home’s statement of purpose to reflect these aims and to detail the new management structure. Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning has improved and now reflects a more person-centred approach and this has led to greater involvement of people in their recovery. EVIDENCE: The individual needs and choice of people using the service have been greatly improved by the recent introduction of a more efficient and effective care planning system. This has included both making people who use the service more aware of the role of the staff, and what is expected of them during their stay. Staff have had training in using different ways of working with people to ensure that people gain maximum benefit from their stay. Another recent development has been the introduction of a more in depth assessment carried out by the home in the first few days of a person’s placement. This has been a positive move as it allows people to make a connection with their keyworker early on in their stay, and to examine the Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 Page 11 issues of their mental health that led to their admission. Staff described the use of these tools to assist in this process, namely a “spider diagram” which visually charts a person’s progress in key areas that affect their mental health, graphically displaying this information at admission and then plotting progress throughout their stay in the home. There was evidence that these were being completed to good standards and involved face-to-face sessions with service users to ensure they were clear on the reasons for their admission and the outcome hoped for. The more person centred approach has led to care plans that have real meaning for individuals and that they were in control of. To support this work risk assessments had also been greatly improved and demonstrated clear steps to support people to achieve success. The following extracts from interviews by the expert by experience demonstrate how people are being helped by the input of staff in the home: “This person was clear that her time in Croftlands had a purpose in that it would lead to independent living at some future date when she was ready to take this step. She reported that the staff were approachable and she had one-to-one meetings with her mentor once a month. She felt she was making a ‘good recovery’.” Another person spoken to by the expert by experience saw his stay in Croftlands as, “a great opportunity” to get on his feet. They were quite clear that he must make the most of his time if he was to fulfil his dream of having a flat of his own in the community ‘unsupervised’. He was also quite clear about the responsibilities involved in self-medication, the need to be responsible for self-care and the need to respect the rules of the establishment. He said that the staff were always willing to stop what they were doing if he wanted to speak to them. This resident has a social worker who visits regularly and he is responsible for handling his own money. He said that when he moved into the home “it felt great” to have his own room and his own space. And finally this final person interviewed gave their views on living at Croftlands, in response to the question about improvements in his mental health, he said that he was one hundred per cent improved and felt that he was receiving excellent physical, emotional, social, and spiritual (personal) Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 Page 12 support. When asked, he gave the home an A* rating. In other words, he judged Croftlands to be “an excellent place to be”. He, too, was quite clear as to why he was in the home, ie, his goal being independent living in, perhaps, a year’s time…. He sees his key worker (mentor) every week for an hour on a one-to-one basis. This is an improvement on the previous monthly visits. He wondered if this improvement might have been brought about because of a previous CSCI inspection. “ Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are well supported to take part in leisure and social activities that promote well-being. EVIDENCE: The service is increasingly successful at providing a safe and therapeutic environment where people can explore the nature of their current illness and personal circumstances. To aid this process the service has strengthened links that promote social inclusion and are aware of good practice models in the mental health field, for example Community Bridge Building. People interviewed by the Expert by Experience gave numerous examples of activities they were being encouraged to engage in for example, one person described a busy schedule each week when they spend time at the local leisure Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 Page 14 centre playing badminton and football, and they are also keen on weight training keeping the equipment in their bedroom. The manager has encouraged staff to play a more pivotal role in peoples recovery and meet with the person they key work on a much more frequent and planned basis. This had previously been done in an adhoc manner. An expectation of staff is that they also record this contact and any important events rather than have a daily record sheet which largely recorded everyday matters that had little relation to people’s mental well-being. Care plans indicated that they are in contact with relevant professionals, such as community psychiatric nurses, to assist in developing their life skills and coping strategies. The home has developed a good balance between risk-taking and a duty of care, and much of the dialogue with people is around rights, choices and developing positive coping strategies. People are therefore treated as individuals and their rights and needs respected and addressed. A significant part of the care offered is to ensure that people have a healthy, good quality diet to promote a persons well-being whilst staying in the Home, and to use this knowledge once they have left. Menus are planned on a weekly basis with people and a communal evening meal is encouraged. People living in the home spoke of very much enjoying the food and appreciate having a cooked meal in the evenings and being able and encouraged to make snacks and light meals across the day. Staff are given training on the importance of healthy diets and the role in promoting good mental health. Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s healthcare is well monitored and they are supported to stay well during their stay. EVIDENCE: Records seen by the inspector confirmed that people have access to a full range of general health care services and more specialised services, such as psychiatrists, community psychiatric nurses (CPN) and behaviour specialists. People spoken to felt staff are approachable and are helping them to achieve greater stability and promote their mental well-being, and felt this support was offered at the right levels, without being too intrusive. Medication handling has under gone a review with a view to making the procedures as safe and robust as possible. An Inspection was carried out by the CSCI pharmacist and recommendations from this visit have now been implemented. The manager has introduced a number of measures to improve the safety and accuracy of the care and dispensing of medications. Staff have been made aware of their responsibilities and their role in supporting residents with their medications as an essential part of their rehabilitation. These measures have included strengthening of the checking in systems and an audit Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 Page 16 check at each staff handover. Every staff member has the target of being as accurate as possible with medications written into their appraisal. Also one shift member is dedicated to medications and any errors are now reported to CSCI and to the homes Operations manager. As a result residents are receiving a much-improved service from the home. Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has improved and strengthened both its complaints and protection procedures to ensure that people using the service are listened to and are safeguarded from harm. EVIDENCE: Croftlands has reviewed its Complaints Policy to separate the investigation of alleged abuse issues from the management of the Project, in line with the most recent good practice guidance coming out of the result of national inquiries. This is also in line with local multi-disciplinary guidance. The manager is now clear that firstly they have to refer allegations of abuse to social services for consideration and to gain multi-disciplinary agreement about how further investigations should be conducted Staff have received training from the project manager on the revised policy, and the manager has enrolled on the next available course for senior managers run by social services. A complaints register and investigation file has been set up and held in the office to record and monitor all formal and informal complaints and concerns. All these revisions ensure that the protection and welfare of people using the service is handled in a professional manner. Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a homely, comfortable house which meets their expectations and needs. EVIDENCE: A domestic has been employed for 2 hrs per week to clean the communal areas, kitchens and bathrooms, as a requirement of the last inspection. Staff reported that this has been an improvement. As part of this requirement the organisation employed a commercial cleaning company to do a one off “spring clean”. The home is now ready for either another “spring clean” or they need to increase the domestics hours on an ongoing basis. The garden has also been allocated a separate budget, as this is very large and in the past has looked unkempt, and it now looks a lot better maintained and this is important for first impressions. The expert by experience commented “My first impressions were of a large, sprawling residence which was obviously ‘lived in’. …..I think that Croftlands is Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 Page 19 as near a ‘proper home’ as is possible given the age of the building and the circumstances of its residents.” And people were very pleased to have their own bedrooms, which they could personalise and that they could also lock. The manager discussed improvements that had been negotiated with the housing association landlord. These included the second kitchen being refurbished and up-grading the bathing facilities. The hallway and three bedrooms are also planned to be redecorated. The manager also intends to work out a planned programme of improvements and particularly wishes to upgrade the quality of bedroom furniture. The expert by experience also commented that the IT facilities were inadequate. As while trying to use the computer to show staff a new resource that would be helpful to their work the dial-up internet was not able to access this site. This is what she reported: “Unfortunately, I was unable to help them access a web site which I thought might be of interest to them. This was because of the age of the computers and the fact that – although there is access to the Internet – Broadband has not yet been installed. I think the installation of Broadband would be an asset to all those concerned in using Information Technology at Croftlands. On reflection, I would also suggest that thought be given to the likelihood that many people coming into the home as residents in the future will be computer literate and access to an up-to-date computer with email would help them keep in touch with their friends and relatives.” This is a legitimate concern and consideration should be given to people accessing the Internet and computers. Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Croftlands staff team has been revitalised by the addition of new staff and the enthusiasm of the newly appointed manager, who together are providing a much more professional service to people. EVIDENCE: Supervisions and appraisals are now part of a Quality Assurance monitoring system for manager, and monthly returns are sent into the organisations HQ for monitoring. Staff reported they were having more regular supervision and felt well supported by the manager. The manager and staff team are reviewing how they work with people and the practice and tools they use to engage people in their recovery. To this end the team is to complete the newly published Ten Essential Capabilities workbook standards, which is a sign of good practice in this field. The expert by experience commented: “I was extremely impressed with the standard of people who are the formal care staff in Croftlands and was given the opportunity to talk to them at length Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 Page 21 during the course of my visit. The Manager of Croftlands is obviously deeply committed to helping both residents and the young members of staff to fulfil their purpose in life. Between them, they have a common goal in that they are helping people move on towards independent living in sheltered accommodation or, in some cases, to take their place as equal and responsible citizens” People spoken to were very complimentary about all the staff, saying they were good at listening and offering the right amount of support to help them get better. Saying to the expert by experience “ the staff are continually updating their knowledge and skills for the benefit of residents.” And when asked what he expected from the service he said, “I expect the best and I get the best”. The Training Matrix, as recommended at the last inspection has been set up and is helping to identify gaps and training needs. Croftlands Trust’s Human Resource Manager and Training Coordinator are working to link core objectives to NVQ and Mental Health Certificate standards to make training as relevant as possible for this setting. As part of this review the organisation should assess which qualification is most relevant to this setting, as NVQ2 is very much directed to the care of the elderly. The level of NVQs held by staff is currently below expected levels, as a number of staff with this training have moved elsewhere within Croftlands Trust. A number of staff have enrolled and the manager has become and NVQ assessor which should help to improve these levels. The service has robust recruitment procedures that include all staff having enhanced level CRB disclosure checks. Upon appointment staff are issued with a handbook, which includes job descriptions and terms and conditions. Appointments are subject to a six-month probationary period. The Croftlands Trust has a code of conduct and all members of staff have a statement of terms and conditions. A new member of staff interviewed confirmed these practices and had felt well equipped by the induction programme. The organisation is further developing this procedure by including service users as part of the selection procedure for new staff. This will be enabled through a newly appointed Service users Participation coordinator. All these measures are creating a more professional and skilled work force that are better able to support and promote peoples well- being. Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home has greatly improved with the appointment of a dedicated manager, however the time allowed for this post is wholly inadequate. EVIDENCE: Since the last inspection the home has been given a dedicated manager, which is an improvement to the manager having other services to run as well. The service is being well managed despite there not being enough management hours allocated to the newly appointed manager. She has worked extremely hard to bring about significant improvements, and has many more plans to develop the service. To do this she is given 3 days per fortnight supernumerary to shift work. This is made worse by the home not having any senior or deputy to share or delegate any tasks to. The organisation must improve these hours and offer better support to the manager. Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 Page 23 The manager has undertaken a review of the home’s Quality Assurance system with the aim of evaluating the consistency and quality of the following: individual needs assessment, Care Plan completion and review, medication records, keyworker diary’s, health and safety reports and the supervision of staff. This has all led to an improvement in record keeping and ensures the quality of care and supported delivered to people in the home. The manager has introduced ways for people to influence the service by increasing key worker one-to-one time and ensuring that house meetings are conducted and surveys are carried out annually. Croftlands DS0000022572.V344159.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 2 2 3 3 x 4 5 CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000022572.V344159.R01.S.doc x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 x 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Croftlands Score 3 3 3 x 3 x 3 x x 3 x Version 5.2 Page 25 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 13(6) Timescale for action Senior staff must receive training 30/09/07 in safeguarding adults procedures Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA33 Good Practice Recommendations The registered manager should have sufficient management hours to run the home as the current hours put undue stress on her. Consideration should be given to providing a senior or deputy to delegate some tasks to. People should be provided with efficient internet access to enable them to communicate and engage in normal activities of their age group. People using the service should be actively encouraged to take part in staff selection 2. 3. YA24 YA34 Croftlands DS0000022572.V344159.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Croftlands DS0000022572.V344159.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. 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