Inspection on 28/11/07 for Dolphin Court

This inspection was carried out on 28th November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Claremont House

Sun Court Nursing Home

Bramley Avenue (73)

15 Bramble Close

Fen Road

Wakes Hall

165 Putnoe Lane

Bishop Herbert House

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

CARE HOME ADULTS 18-65 Dolphin Court 179-182 Eastern Esplanade Thorpe Bay Essex SS1 3AA Lead Inspector Mr Trevor Davey Unannounced Inspection 28th November 2007 10:30 Dolphin Court DS0000070261.V355609.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 Dolphin Court DS0000070261.V355609.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. Dolphin Court DS0000070261.V355609.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dolphin Court Address 179-182 Eastern Esplanade Thorpe Bay Essex SS1 3AA 01702 584088 01702 589947 manthorpebay@grooms-shaftesbury.org.uk www.grooms-shaftesbury.org.uk Grooms-Shaftesbury 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) Mr Louis Chan-Kee Care Home 17 Category(ies) of Physical disability (17) registration, with number of places Dolphin Court DS0000070261.V355609.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New Service Brief Description of the Service: Dolphin Court is registered to provide personal care with accommodation for 17 younger adults who have a physical disability. Dolphin Court was previously registered as part of the John Grooms Association until merging with Shaftesbury on 29th June 2007. The home aims to provide facilities and support to enable residents to move on to independent living or supported housing. Facilities are sited on three floors and a shaft lift is available. Accommodation includes 13 single and two double occupancy flats. Each single flat has a bed sitting room and the double flats have a separate bedroom. All flats have a separate bathroom and kitchen. The home has a communal dining room on the ground floor which doubles as the lounge. A conservatory has also been provided to give alternative communal space. There is car parking at the rear of the building. There is a limited decked garden area and summerhouse. The home is situated on a main road, approximately 2 miles from the centre of Southend. There is a local bus service and the home also has its own vehicle for transporting residents. The current rate of fees is £735 per week. Additional charges are made for hairdressing, chiropody, activities, papers/magazines, medical requisites, holidays and transport. Information about the home is made available to prospective residents in the Statement of Purpose and Service User’s Guide. Dolphin Court DS0000070261.V355609.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection site visit covered a period of 9.25 hours and covered all key standards. The Registered Manager, deputy and head of care for the home, together with staff and residents were available during the site visit and were spoken with. Their comments and contributions received were helpful in assisting the Inspector to prepare the report. As part of the site visit, a tour of the premises took place. Personal care records and other official records within the home were also inspected. The information included in the annual quality assurance assessment form (AQAA) which had been submitted to the Commission for Social Care Inspection, was also used in compiling the inspection report. This form gives homes the opportunity of recording what they do well, what they could do better, what has improved as well as future plans for improving the service. Feedback from survey information, which the home itself had obtained, was also inspected. Matters relating to the outcome of this inspection were discussed with the management team. Full opportunity was given for discussion and/or clarification both during and at the end of the site visit. What the service does well: The management and staff team are committed to promoting high quality care together with support to ensure that so far as possible, individual aspirations are met. The home has been able to demonstrate that they are good at listening to residents both as a group and also on an individual basis. This is achieved by giving residents the opportunity to complete audit questionnaires, attending residents meetings as well as communicating on a day-to-day basis with individual members of staff. This has meant residents have had more opportunity of pursuing individual interests and activities of their choice. The home has been successful in enabling former residents to move into independent living accommodation in the community. Care plans, risk assessments and review information, is easy to follow, detailed and reflects the identified needs together with the support required. Individual residents are consulted and involved in this process. Many of the residents spoken with, confirmed that their individual preferences, dignity, and privacy were all respected by staff. Dolphin Court DS0000070261.V355609.R01.S.doc Version 5.2 Page 6 Staff recruitment information, induction and training records were available and properly maintained. The home is good at identifying training topics and providing courses which are relevant to improving the skills of the staff team as well as promoting the safety and welfare of residents. 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. Dolphin Court DS0000070261.V355609.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 Dolphin Court DS0000070261.V355609.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): 2 People who use the service experience excellent quality outcomes in this area. Potential residents, families and interested parties can be assured of a robust pre-admission assessment to ensure that the proposed placement is suitable. This judgement has been made using available evidence including a visit to the service. EVIDENCE: An inspection was carried out of pre-admission assessment information related to recent admissions to the home. This included medical care, social, psychological information as well as a medical enquiry form completed by the doctor concerned. In addition, details were available which had been submitted by the sponsoring authority and an adult assessment had also been completed by the social worker involved. This was a recent admission and care plans were in the process of being developed. The Inspector spoke with one of the new residents who confirmed that the manager and head of care had carried out a visit whilst in a previous residential care home. The social worker was also involved in this process. An information pack about the home and application form had also been given to the new resident during this visit. Detailed information had been given to the potential resident about the service available and how this could be provided to suit individual needs. The Dolphin Court DS0000070261.V355609.R01.S.doc Version 5.2 Page 9 Inspector was also advised that an opportunity had been given to ask questions. The pre-admission process included a visit to Dolphin Court that included lunch and a tour round the premises as well as seeing the accommodation which would be made available. Staff were said to be very kind, professional and advice had also given about care planning and how this works. Although only recently admitted, medical appointments had already been arranged and social interests discussed. Staff were said to be welcoming and supportive. Every opportunity had been given to exercise independence as well as expressing views about individual preferences. It was evident from conversations and records inspected, that potential residents had been appropriately assessed to ensure the home could meet their needs. Dolphin Court DS0000070261.V355609.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 People who use the service experience excellent quality outcomes in this area. Residents can expect to have a plan of care drawn up by the home that reflects their wishes and details their assessed needs. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Three sets of personal care records were inspected that included care plans, risk assessments and evaluation/review information. The format of care plans was clearly set out and included information relating to the activity, problem, goal an action to be taken as well as evaluation reports. Care plans were specific and included identified need, help required as well as the equipment needed where appropriate. Examples of care plans completed were bathing, washing, continence assessments, communication, domestic skills, education, eating and drinking. Some of the residents spoken with also confirmed that they were involved in these discussions and the decision-making process which Dolphin Court DS0000070261.V355609.R01.S.doc Version 5.2 Page 11 had been recorded. Risk assessments were clearly documented identifying action leading to risk, contributory factors as well as the hazards and risks involved. The records were also helpful in indicating residents understanding and awareness of potential risks and hazards. As part of this information, residents comments relevant to the assessment and the risk reduction actions agreed, had been recorded. Examples of risk assessments completed included showering, dealing with finances, mobility and self-medication. Comments made by residents spoken with were generally positive and staff were said to be friendly and very helpful. Other comments made by residents also demonstrated that when going out together, staff understood and respected the right of residents to have private conversations with each other. Information was available showing activities and events that residents themselves had chosen which included cricket matches, rock and blues nights in the lounge and quiz evenings. The Inspector also took the opportunity of attending a residents meeting during the site visit and 10 residents attended. Minutes of previous meetings were available and items discussed included furnishings and improvements to the home, garden projects, Christmas arrangements as well as escorting arrangements when visiting local churches. Residents were invited as a group and also as individuals to ask questions and to make comments. As part of the homes quality assurance arrangements, the Registered Provider has one person on behalf of the organisation who is responsible for collating this information. The home also has volunteers from the Friends of Dolphin Court who come in and assist some of the residents with completing survey questionnaires. All these measures demonstrate the home is providing opportunity for individual needs and preferences to be expressed as well as enabling residents to pursue an improved lifestyle in accordance with their choice. Dolphin Court DS0000070261.V355609.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 People who use the service experience excellent quality outcomes in this area. Residents can expect to be supported in participating and experiencing a variety of social and leisure activities and be provided with a balanced varied diet. This judgement has been made using available evidence including a visit to the service. EVIDENCE: From discussion, observation and records available, there is evidence to show that residents are encouraged to enjoy and take part in leisure and recreation activities which reflect individual choice and interest. One of the staff members who is responsible for co-ordinating social activities on behalf of residents, spoke with the Inspector and explained how individual interests are identified. This process includes one-to-one conversations with residents to discover particular hobbies and leisure activities. Where residents had been Dolphin Court DS0000070261.V355609.R01.S.doc Version 5.2 Page 13 involved, these had been recorded and included swimming, art and craft and visits to garden centres. Where appropriate, residents are also taken to the job centre with a view to obtaining part-time employment. Many of the residents attend college which included sessions for pottery, painting and various art and craft classes. Residents also attend other leisure activities including riding lessons, visits to the cinema, games afternoons and pub visits. Evaluation forms had been completed following the completion of each activity and included the names of residents, dates of attendance and any relevant comments by the staff team. A review of activities is carried out six monthly. The home has two vehicles for transporting residents on outings to these other activities. Some of the residents spoken with confirmed that they were able to visit members of their family and friends at weekends as well as attending church services of their choice. Some of the residents had formed close friendships and the home facilitates relationships in accordance with the intentions and wishes of individuals. During the site visit, staff were observed assisting residents in writing Christmas cards and being available in other supporting roles as required whilst at the same time, allowing residents freedom to exercise their independence. Other residents spoken with confirmed that staff accompanied them to the shops and the bank as well as discussing various leisure activities. From the self-assessment (AQAA) form completed by the home, they are hoping to recruit more volunteers to work on a one -to -one basis to improve on residents personal development. A number of residents were spoken with during lunch and they confirmed that they do have the opportunity of choosing meals and planning menus although sometimes this is two weeks in advance and people tend to forget what they have selected. Roast pork and vegetables was provided for lunch but other alternatives were also available that residents had chosen. These included jacket potatoes, cheese and coleslaw. Some residents also commented that they had been taken to the shops to buy food. They also had the opportunity of preparing their own breakfast but that assistance was available if required. The Inspector spoke with the cook who is available from Monday to Friday. At weekends residents prepare their own meals with the assistance of staff. Records of meals provided to individual residents were made available for inspection. These included three options for the main meal and on the day of the site visit, these included roast pork and vegetables, cod fishcakes and salad as well as jacket potato, cheese, beans and salad. There was also fresh fruit available on the tables. Evenings with a special theme had also been arranged which included an Italian meal that residents had helped to prepare. Records were being maintained of fridge and freezer temperatures, cleaning schedules as well as a checklist of pest infection control procedures. Dolphin Court DS0000070261.V355609.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 People who use the service experience excellent quality outcomes in this area. Residents can expect to receive good health and personal care support. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The philosophy of care in the home includes giving residents every opportunity to be involved in discussions and making decisions relating to their personal care and the support they are to receive. Personalised care plans were detailed and comprehensive and covered the holistic needs of residents. These included manual handling, pain control and epilepsy seizure records. Mobility and wheelchair assessments were also in place. Night care assessments had been prepared which included information regarding incontinence aids where appropriate. Provision was available in the documentation for residents or their advocates to confirm their agreement to care plans and risk assessments. Diary notes for individual residents were also made available for inspection which included information regarding medical care and doctor appointments as well as changes to medication. Some of the residents spoken with confirmed Dolphin Court DS0000070261.V355609.R01.S.doc Version 5.2 Page 15 that they had found staff helpful and supportive when having to discuss and make decisions regarding their care, which in some cases included looking at future possibilities for more independent living in the community. Residents also confirmed that other health care arrangements had been discussed with them which included physiotherapy and hydrotherapy. A check was made of the medication administrative arrangements in the home and from the sample checks made, the medication administrative records (M.A.R.) were being completed in accordance with agreed procedures. At the time of the site visit, twelve residents were self-medicating and a lockable storage facility was available in individual flats. Risk assessments had also been prepared and individual protocols had been signed by the resident concerned and a member of the staff team. Protocols for P.R.N. (to be taken as required) medication had been prepared and signed by staff and evidence of changes to medication, had been confirmed by a doctors letter, fax from the surgery or two staff signatures on the M.A.R. sheets. These recording procedures had been improved since the last inspection. Records were also available showing receipts where disused drugs had been returned to the pharmacist. One resident was receiving controlled drugs and the register had been properly completed and maintained up-to-date in accordance with the agreed practices. Dolphin Court DS0000070261.V355609.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good quality outcomes in this area. Residents can expect to have their complaints taken seriously and be assured that they will be protected by the homes safeguarding adults from harm procedures. This judgment has been made using available evidence including a visit to the service. EVIDENCE: The home has a complaints procedure which is sent out in the Statement of Purpose and Service User’s Guide/brochure. There have been no recorded complaints since the last inspection. Some of the residents spoken with had been made aware of the complaints procedure. The home was able to demonstrate that through individual conversations and residents’ meetings, there is opportunity for issues to be raised and views expressed. Records were available to show that staff had attended safeguarding adults from harm training. There has been one reported occurrence regarding a safeguarding issue relating to the conduct of a member of staff and this was referred to the local authority Safeguarding Vulnerable Adults Co-ordinator. The home was able to demonstrate that appropriate measures were taken under their safeguarding and disciplinary procedures to protect residents and this issue was properly dealt with to the satisfaction of the Commission for social Care Inspection. Dolphin Court DS0000070261.V355609.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 and 30 People who use the service experience good quality outcomes in this area. Residents can expect to live in a clean, safe and comfortable environment. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The premises of the home were clean, hygienic and no concerns were expressed by residents regarding the cleanliness of their flats. Paper towels, liquid soap and hand dispensers had been provided throughout the home and there were no unpleasant odours. Staff were trained and following procedures to minimise the risk of infection in the home. In their self-assessment (AQAA) form, the home states that as part of the improvements during the past twelve months, additional beds and mattresses had been purchased. These are customised beds to meet specific assessed care needs of individual residents. A new conservatory had also been built which provides an alternative quiet area where residents can see visitors if Dolphin Court DS0000070261.V355609.R01.S.doc Version 5.2 Page 18 they wish. At the residents’ meeting, the manager mentioned that a new ramp was on order to provide more suitable access into the garden area. Colour swatches were also going to be made available for residents to choose new blinds for the conservatory. A summerhouse had been purchased to give additional space for outdoor activities. The home is actively involved in raising funds to build a new garden area for the benefit of residents within the next twelve months. Dolphin Court DS0000070261.V355609.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 People who use the service experience good quality outcomes in this area. Residents can expect to be cared for by suitable numbers of staff on each shift which meet their needs. Residents can be assured that records will be able to demonstrate that the home has followed robust recruitment and employment procedures. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Staff rotas were available which identified the designation of staff and hours worked. Staffing ratios are arranged on the basis of the assessed/identified needs of residents matched with the support required. The manager, deputy and head of care are on duty during the early and late shifts and these three management staff cover weekend emergency calls on a rotating basis. In addition, there is a team leader with two care assistants but a third care assistant is rostered for duty if a team leader is not available. An activities organiser is also employed for 30 hours per week and other and ancillary staff consisting of cook, two or three home carers (domestics), full-time Dolphin Court DS0000070261.V355609.R01.S.doc Version 5.2 Page 20 driver/handyman and a part-time handyman are part of the staffing establishment. Night cover is provided by two staff who sleep in on the premises on a rostered basis and who are available to give assistance to residents as required. Staff recruitment records were in place and these were inspected for some of the more recent appointments. A checklist was available which included a photograph, proof of identification, medical questionnaire, application forms, two references, Criminal Record Bureau checks, letters and contracts of employment. A record was also available of Protection Of Vulnerable Adults (P.O.V.A.) first checks. Induction records were in place for new staff which included safeguarding adults from harm procedures, manual handling, medication practices, brain injury and H.I.V. awareness. Other training records were available which included courses attended by staff covering spinal injury and associated emotional trauma. All staff receive regular updates in training for moving and handling which includes the use of workbooks. Epilepsy awareness and seizure management training is provided and first aid training is covered every three years. Records were available showing the names of staff who had attended these courses. At the time of the site visit, five staff were studying for the National Vocational Qualification level 2 course and other staff had achieved levels 2 and 3. The head of care was currently studying for the National Vocational Qualification level 4 Registered Managers Award. In their selfassessment (AQAA) form the home state that they are working towards all staff achieving the National Vocational Qualification. Minutes were available of staff meetings which are held every two months and in addition, separate team leaders’ meetings also take place. Dolphin Court DS0000070261.V355609.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 People who use the service experience excellent quality outcomes in this area. Residents can expect to live and be supported in a home where the management and administration of the service is excellent. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The registered manager has considerable managerial experience and has developed a management team together with a staffing establishment, that work together to support and improve the quality of life for residents. The management team have specific areas of dedicated responsibility. Policies and procedures are regularly reviewed and good communications systems exist within the staff group. One-to-one staff supervision regularly takes place. Any Dolphin Court DS0000070261.V355609.R01.S.doc Version 5.2 Page 22 requirements and recommendations from previous inspections have been met. In the self-assessment (AQAA) form completed by the home, reference is made to the organisations quality audit which included positive feedback from residents, families and outside professionals. This is part of the registered provider’s policy for quality assurance which is consistent in reviewing and improving the service of the home. This demonstrates the homes commitment to improving the quality of life for residents. Regular monthly Regulation 26 reports are submitted to the CSCI to demonstrate that regular monitoring of the service takes place on behalf of the Responsible Individual. With the merger of John Grooms with the Shaftesbury organisation, the format of this report is being reviewed within the next twelve months to show greater detail and information when monitoring visits are made. A sample check was made of health and safety servicing agreements and these had been reviewed with evidence of maintenance being carried out on a regular basis to services and equipment. A risk assessment for fire precautions had been carried out and assessments for a safe working environment had been reviewed and updated. Dolphin Court DS0000070261.V355609.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 4 2 x 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 4 33 4 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 4 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 x 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 4 x 3 x x 3 x Dolphin Court DS0000070261.V355609.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA17 Good Practice Recommendations Residents should have the opportunity to select and plan their preferred choice of meals on a more frequent basis rather than at two–weekly intervals. This enables residents to remember more easily what they have chosen. Dolphin Court DS0000070261.V355609.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Dolphin Court DS0000070261.V355609.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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