Inspection on 13/08/08 for Deerhurst

This inspection was carried out on 13th August 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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Extracts from inspection reports are licensed from CQC, this page was updated on 28/10/2008.

CARE HOME ADULTS 18-65 Deerhurst 20 Deerleap Way New Milton Hampshire BH25 5EU Lead Inspector Pat Trim Unannounced Inspection 13th August 2008 09:30 Deerhurst DS0000071737.V369132.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 Deerhurst DS0000071737.V369132.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. Deerhurst DS0000071737.V369132.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Deerhurst Address 20 Deerleap Way New Milton Hampshire BH25 5EU 01425 619952 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) Contemplation Care Ltd Mr Christopher William Taylor Care Home 3 Category(ies) of Learning disability (0) registration, with number of places Deerhurst DS0000071737.V369132.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 3. Date of last inspection Brief Description of the Service: Deerhurst is a large family home situated in a quiet residential area near New Milton. It has 3 single bedrooms with a shared bathroom and toilet on the first floor. The ground floor has a large lounge/dining room and conservatory that everyone can use, a toilet, a kitchen and the office. There is a big garden and patio area. The home was bought, with two other homes, from the previous providers in March 2008 by Contemplation Care Ltd. It provides support for up to three people who have a learning disability. The fees are from £950. 00 to £1614.00 per week. Deerhurst DS0000071737.V369132.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means people who use this service experience adequate quality outcomes. The information used to write this report was obtained in the following ways. We looked to see if we had received any complaints about the home and saw that we had not. We also looked at any information the home had given us about what might have happened since we visited. We used some of the information the provider gave us about the home in a form called the Annual Quality Assurance Assessment (AQAA). This is a form the home has to fill out every year to tell us what they are doing to make sure the home gives the people who have used the service the care that they want. We also used information we received from surveys. We sent surveys to all three people who use the service to ask what they thought about it. We received three surveys back. We sent four staff surveys to the home and asked them to give them to staff. We received four surveys back. A five hour visit was made to the home by one inspector to carry out a key unannounced inspection. During the visit time was spent talking with all three of the people who use the service to get their views about it. Some people in the home have limited verbal communication, so time was also spent observing staff practice and the interactions between people who use the service and staff. Time was also spent discussing the provider’s plans for the home and looking at the environment. A random selection of documents was viewed. The three people who use the service were case tracked. This means their records were looked at to see how the provider identified their needs and made sure they were met. What the service does well: The people who live in the home say they like living there and like the staff. They all like to do things differently and staff work hard to help each of them do the things they enjoy. They all said staff listen to them and do what they want them to most of the time. Nearly all the staff have completed a qualification that helps them do their job. This is called a National Vocational Qualification (NVQ). Deerhurst DS0000071737.V369132.R01.S.doc Version 5.2 Page 6 People that use the service said they liked the space they had; the fact the home was small and their rooms. They liked choosing the colours when their rooms were redecorated. 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. Deerhurst DS0000071737.V369132.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 Deerhurst DS0000071737.V369132.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): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed pre admission assessments are completed that enable the registered manager to be sure people who use the service will only be offered a place if the home can meet their needs. EVIDENCE: The home had not admitted anyone new to the service since the new providers took over. Feedback from the 3 people who used the service showed they had been involved in the decision to move there. One person said ‘I was invited to have a look at the home before I moved there. I used to live in Denehurst but moved here because I did not like living with a lot of people.’ The registered manager said the admission process had not changed since the new providers took over the home. The AQAA stated the admission process included the completion of an in depth assessment and visits to the home. Deerhurst DS0000071737.V369132.R01.S.doc Version 5.2 Page 9 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 adequate. This judgement has been made using available evidence including a visit to this service. Care plans are written in a way that does not enable the person to be involved in identifying their abilities, needs and wishes or to amend them when their needs change. Risk assessment is used to identify and minimise any risks involved in activities people who use the service wish to take part in. EVIDENCE: Each person who uses the service had an individual care plan, a daily routine summary, a person centred plan and an activities sheet. This means that information about the person is recorded in a number of different places, which makes it difficult to see the overall abilities, needs and aspirations of the person in every aspect of their lives. Each section of the main care plan had a list that was signed each month to show the plan had been reviewed but there was no evidence as to how this monthly review had been carried out. Each record stated ‘no change,’ Deerhurst DS0000071737.V369132.R01.S.doc Version 5.2 Page 10 although there was evidence that the mental health needs of two people had changed recently. The registered manager said he was aware the current care plan system was complex and needed reviewing. He had been going to do this when the new providers took over. The responsible individual had already stated at an inspection of one of the other services that the current care planning system was to be reviewed to ensure people who use the service have a care plan that identifies and meets all their needs. The new system will be based on the use of a person centred plan that involves the people who use the service and has a range of reviewing tools. There was evidence that although the care plans did not reflect the changing needs of people who used the service, they were identified and appropriate referrals made. For example, one person had been referred to Adult Services for a new assessment of need to be completed. Two people had recently been referred to health care professionals. Restrictions imposed on people who use the service have been agreed at a multi-agency level and the reasons for the restrictions explained to the person involved. For example, the kitchen is kept locked for much of the day, as there is a reason for each person in the home to have limited access. An individual risk assessment for each person is in place to show why this restriction is necessary. One person, who has to have their fluid intake limited, is enabled through risk assessment to go and make their own drinks, supported by staff. The person has had the reasons for the restriction explained to them and is able to say why this is. The same person has anxiety problems and can become very agitated. A risk assessment has been put in place that identifies triggers likely to increase the person’s agitation, together with an action plan that helps staff defuse stressful situations. The plan leads staff through a number of steps before moving to the medication plan. Deerhurst DS0000071737.V369132.R01.S.doc Version 5.2 Page 11 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): 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to make choices about their lifestyle and to live their lives in the way they wish, but some care practice limits the rights of people living in the home to be treated with dignity or respect. EVIDENCE: People who use the service did not have a lot of regular activities recorded in their care plans. The registered manager said each of the people currently living in the home did not like a wide range of activities and did not enjoy doing things together. Evidence from care management and health care assessments supported this comment. Individual plans identify what is important to each person and activities and support are offered to enable them to do some of these things. For example, the plan for one person recorded they liked to answer the front door. They were seen being able to do this throughout the day. Another person liked to Deerhurst DS0000071737.V369132.R01.S.doc Version 5.2 Page 12 listen to music and were seen choosing what to listen to with staff. A third liked to contact their family every evening and said they were supported to do this. Regular activities for some people included going to a local social club to see friends once a week and to a workshop once a week. They are also offered trips out with staff and some of the people from the other homes. This has included a recent trip to a local football club, shopping, and a pub. People who use the service are offered in house activities to meet their identified needs. The plan for one person identified they liked to do things in the morning and rest in the afternoon. Staff offer activities such as listening to music, the German language or doing exercises in the morning, leaving the afternoon free. Another person likes to watch films and is able to do this on their own in the main lounge, whilst the third person listens to music with a member of staff in the conservatory. There is no plan of regular activities apart from the weekly trips already referred to. Instead a record is kept of any activities done by people who use the service and also of anything offered and refused. The record for one person had several entries that indicated their rights to be treated with dignity, respect and as an adult had been compromised by some staff not allowing them to do the activities of their choice because of their behaviour. The entries were shown to the registered manager who agreed the action taken by staff did not uphold the person’s rights. The responsible individual was contacted, who stated that immediate investigation would be carried out and appropriate action taken. In a telephone call the next day she confirmed representatives of the organisation were visiting the home and that the commission would be kept informed of the outcome. The AQAA stated that ‘Menus are to be revised and improved to promote choice and the provision of a nutritionally balanced diet.’ A record is kept of the meals currently provided and showed that people are able to choose what they eat for breakfast and tea and can choose an alternative to the main meal. The registered manager said he makes sure fresh salad and vegetables are regularly offered and the people who live in the home encouraged to make healthy choices as much as possible. People who use the service said they liked their food and enjoyed choosing what they were going to have. Deerhurst DS0000071737.V369132.R01.S.doc Version 5.2 Page 13 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 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive daily routine plans make sure that staff have the information they need to provide personal care in the way each person likes it. People who use the service have access to a wide range of health care that ensures their health care needs are monitored and met. Staff have the training and guidance they need to manage medication safely, which minimises the risks to the people who use the service. EVIDENCE: The daily plans identify the preferred personal routine of each person who uses the service and informs staff what they can do for themselves and what help they need. For example, one person is able to choose what they wear each day, but needs plenty of time to get ready so staff have to let them know well in advance if they are going out. Another person, who has sight problems, is able to dress independently if staff lay their clothes out for them on the bed. People who use the service have good access to health care. One person said they had recently had new glasses and regularly saw the dentist. Another was Deerhurst DS0000071737.V369132.R01.S.doc Version 5.2 Page 14 going to the doctors that day for a regular check up and records showed that people had relevant health care checks as required. One person has a regular care programme approach (CPA) review and a copy of the most recent was seen on file. The registered manager had raised concerns about the person’s mental health and relevant referrals had been made to health care professionals. The Learning Disability Community Team was currently monitoring the person’s mental health. A second person had been showing signs of deteriorating wellbeing and this had resulted in a referral to Adult Services to review the current care arrangements. The person had also been referred to their psychiatric consultant for help and advice on medication and mental health wellbeing. The home currently monitors everyone’s weight, but the AQAA stated a monitoring tool is to be introduced that will enable the registered manager to identify when there is cause for concern. The home has a policy and procedure for the safe management of medication. The registered manager said only staff who have completed training are permitted to give medication and that a training course has been arranged for all staff. The majority of medication is provided in a monitored dosage system. A record is kept of medication given. One record was checked against the supply remaining and found to be correct. The registered manager keeps a record of all medication received into the home and any returned to the pharmacist unused. Controlled drugs are stored safely but the cupboard used does not comply with the Royal Pharmaceutical guidelines. The registered manager said a new cupboard had already been ordered and was due to be fitted shortly. An appropriate recording system was in place for controlled drugs. Staff have guidance on the use of medication to be given ‘as required’ but this needs to be reviewed following recent medication changes for one person to make sure it still provides accurate and clear guidance for staff to follow. Deerhurst DS0000071737.V369132.R01.S.doc Version 5.2 Page 15 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 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to an effective complaints procedure. Staff have the information and training they need to protect people who use the service from abuse. EVIDENCE: Feedback from the 3 people using the service showed they knew how to make complaints. The complaints procedure is available in a number of formats, including audiotape. One person who uses the service said they felt able to take any concerns to the registered manager and thought he would listen. Another person said they did sometimes tell staff if they were unhappy. The AQAA recorded that no complaints had been received since the new providers took over. The commission had not received any complaints. The home has a policy and procedure in respect of the safeguarding of vulnerable adults. The registered manager attended safeguarding training in February this year and staff have all had recent training. The AQAA recorded that all staff would be required to attend regular refresher training. The registered manager said staff had restraint training and a conflict management course had been arranged for this month for all staff. People had an individual plan to manage possible challenging behaviour. This made it clear that restraint could only be used as a last resort and must be carried out by staff who had received training. There was clear guidance on Deerhurst DS0000071737.V369132.R01.S.doc Version 5.2 Page 16 the level of restraint that could be used. The plan also identified possible triggers and gave staff guidance on methods of diffusion to be used first. The plan linked to the guidance for medication, which was prescribed as ‘when required.’ The guidance did not tell staff to record when restraint was used, but the registered manager said staff knew there was a form they were required to complete. However, he agreed to add this to the guidance. The registered manager demonstrated his understanding of the safeguarding procedure by making an appropriate referral to adult services following an alleged incident. The providers are working with adult services to resolve the issues raised by the incident. Individual records are kept of money held on behalf of people who use the service. Any income and expenditure is recorded and receipts are kept. The registered manager said the money held is checked against the record twice a week and signed to evidence this. The providers will be introducing their own system for managing peoples’ money. Deerhurst DS0000071737.V369132.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment. EVIDENCE: The house is a family-type home and everyone has their own room. There is a large lounge/diner and a conservatory so people can spend time apart from each other if they wish to. The facilities manager said the providers are replacing furniture to provide a more comfortable environment. A new television, washing machine and dryer have already been purchased. People living in the home said they liked their rooms and were looking forward to having them redecorated in colours of their own choice. Deerhurst DS0000071737.V369132.R01.S.doc Version 5.2 Page 18 It was noted that hand basins in the bathroom and downstairs toilet did not have plugs. The registered manager said he would get them replaced immediately. The upstairs bathroom has the facility to have a padlock put on it. The registered manager said the bathroom is not ever locked from outside and agreed to have this removed. Following the advice of occupational therapist, the handle for one person’s bedroom door has been replaced with one that makes it easier for them to open it. This means they can no longer lock their bedroom door. The person has signed a waiver to say they agree with this action, but the registered manager agreed to look into alternative ways of meeting the person’s needs, whilst enabling them to lock their room. Another person has a key to their room, but keeps it in the registered manager’s office. The person said this was because they got anxious if they kept the key and they were happy with this arrangement. As stated in a previous section of this report, the kitchen is locked for much of the day because of the risk to the 3 people currently living in the home. This practice would need to be reviewed if anyone new moved into the home. Staff have had recent training in infection control and the registered manager and one staff have attended a course on MRSA. Paper towels are not used in the toilets. The registered manager said this was because there had been a problem with the toilets being blocked with them. A procedure is in place to make sure the hand towel is changed twice a day. Deerhurst DS0000071737.V369132.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. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Staff receive induction, training and supervision that enables them support the people who use the service. Staffing levels are not always sufficient to meet the needs of the people who live in the home. The home operates a robust staff recruitment procedure to protect people who live in the home. EVIDENCE: The rota showed normal staffing levels during the day are two staff working in the home from 8 a.m. until 6 p.m. This included the registered manager. The 3 people living in the home have very diverse needs. This means they often require 1 to 1 support with any activities, which is not always possible with the current staffing levels. The registered manager said this had already been discussed with the new providers and meetings had been arranged with adult services. Discussions were taking place about the various options available to improve the current arrangements. Deerhurst DS0000071737.V369132.R01.S.doc Version 5.2 Page 20 The home exceeds the standard for staff holding a National Vocational Qualification (NVQ). The AQAA recorded that 9 of the 10 staff have achieved it and 1 staff is completing it. Certificates were seen to evidence this for 6 staff. The registered manager said 2 staff were completing NVQ 3. The registered manager said only one new member of staff had been employed since the new providers took over and that no changes had been made yet to the recruitment procedure. The file for the new member of staff showed the procedure had been followed. Checks included completing an application form, providing a full employment history, two references, proof of identity and having a Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) check completed before starting work. Feedback from 4 staff surveys evidenced they felt the recruitment process was thorough and fair. The new member of staff had completed an induction programme based on Skills for Care guidance. Feedback from 4 staff surveys showed that they thought their induction provided most of the information and training they needed. The providers stated in the AQAA that they plan to introduce a new induction that is based on the Learning Disability Induction Award, as this is more useful for staff working in this field. The new providers are introducing a training matrix that will enable the registered manager to monitor staff training needs. He will be supported in this by the organisation’s training co-ordinator. Recent staff training has included a moving and handling course and medication and conflict management courses have been booked. Feedback from staff showed they receive regular supervision from the registered manager. A written record is completed of these sessions. The registered manager has completed a relevant supervision and appraisal course. Deerhurst DS0000071737.V369132.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Effective quality assurance systems are being developed by the service providers, which will enable them to monitor and develop all aspects of service provision. EVIDENCE: The AQAA stated that the registered manager had 11 years experience of working in the care industry, had been managing Deerhurst for 3 years and was completing his Registered Manager’s Award. The people who use the service said they ‘liked Chris very much’ and that he was always there to speak to if they needed him. Some aspects of management need to be improved, such as monitoring staff practice to make sure it does not compromise the rights of the people who use Deerhurst DS0000071737.V369132.R01.S.doc Version 5.2 Page 22 the service. Care planning needs to be simplified so that the people using the service can be actively involved in identifying their needs and wishes. A system of effective reviewing of care plans also needs to be introduced that will enable the people using the service to be involved. The responsible individual said the new organisation is able to offer strong management support and will be helping the registered manager to address issues raised in the report. The AQAA was completed within the required timescale and identified areas the providers wish to improve, together with a plan for implementing the changes, which will enhance the lives of the people who use the service. The AQAA recorded that the providers will be introducing their own quality assurance system, which will include regular monitoring of service provision. Regulation 26 visits by the responsible individual are being carried out and a copy of the report this visit generates is kept at the home so the registered manager can refer to it. The registered manager said he did not hold house meetings as this had been tried and found not to work. Instead he held individual meetings with the people who used the service and had written records of these meetings. The new training matrix will enable the registered manager to monitor staff training and to identify when refresher training is needed. Staff have had training in health and safety subjects such as moving and handling, food hygiene and infection control. The AQAA recorded that the home complies with health and safety legislation and that all equipment is regularly serviced. A random selection of documents seen during the visit confirmed this statement. Deerhurst DS0000071737.V369132.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 “ ” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X Deerhurst DS0000071737.V369132.R01.S.doc Version 5.2 Page 24 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 YA16 Regulation 12(4)(a) Requirement Strategies for working with the people who use the service must always address their dignity, respect and adult status to ensure that their wellbeing is promoted. Timescale for action 03/09/08 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 Deerhurst DS0000071737.V369132.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Deerhurst DS0000071737.V369132.R01.S.doc Version 5.2 Page 26 - 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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