Inspection on 04/07/07 for Donec

This inspection was carried out on 4th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Donec 03/07/08

Donec 15/11/06

Donec 20/12/05

Donec 06/09/05

Donec 17/01/05

Donec 02/06/04

Donec 29/01/04

Donec 14/11/03

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Donec Headley Road Grayshott Hindhead Surrey GU26 6DP Lead Inspector Michael Gough Unannounced Inspection 4th July 2007 10:00 Donec DS0000011876.V338750.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 Donec DS0000011876.V338750.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. Donec DS0000011876.V338750.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Donec Address Headley Road Grayshott Hindhead Surrey GU26 6DP 01428 605525 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) www.efitzroy.org.uk Elizabeth Fitzroy Support Post Vacant Care Home 14 Category(ies) of Learning disability (14), Physical disability (3) registration, with number of places Donec DS0000011876.V338750.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2006 Brief Description of the Service: Donec, is managed by Elizabeth Fitzroy Support, and is registered to provide a service for fourteen adults with a learning disability or physical disability. The home has links with local General Practitioners, the Community Nursing Team and local community. Donec is a large three-storey house on the outskirts of Grayshott, a small village on the Surrey and Hampshire border. There is no lift available and is therefore appropriate only for service users with good mobility. Service users are able to access local facilities and are encouraged to maintain their independence. Visitors are welcome and service users families are encouraged to play an active part in their relatives life. Information provided by the manager confirms the fees are currently £606.48 to £1199.78 per week and service users are responsible for paying for their own toiletries and items of a personal nature. Donec DS0000011876.V338750.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the evaluation of the quality of the service provided at Donec and takes into account the accumulated evidence of the activity at the home since the last inspection, which was carried out on the 15 November 2006. The inspection took into account the homes Annual Quality Assurance Assessment (AQAA); and comment cards received from 2 service users, 1 care manager and 1 GP. Included in the inspection was an unannounced site visit to the home, which took place on the 4 July 2007. Other evidence for this report was obtained from reading and inspecting records, touring the home and from observing the interaction between staff and service users. It was also possible to gain the views of people living at the home and the inspector had the opportunity to speak with 2 service users, an independent advocate who supports service users at the home, 4 members of staff and by speaking with both of the homes deputy managers, who assisted the inspector during the visit. The home is registered to provide support for 14 service users who have a learning disability and at the time of the inspection there were 13 service users living at the home. What the service does well: The home provides care and support to enable service users to live fulfilling and meaningful lives. Service users are given choice in their day-to-day lives with appropriate support provided by staff at the home and an independent advocate also provides support to service users. Each service user has a key worker who assists individual service users to be involved as much as possible in the day to day running of the home. Service users are supported to access the local community and to undertake leisure pursuits of their choice and all service users attend day service activities. Donec DS0000011876.V338750.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. Donec DS0000011876.V338750.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 Donec DS0000011876.V338750.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that there will be a detailed assessment of their individual needs before they move into the home. EVIDENCE: The AQAA and also information gained at the site visit showed that there has been no new service users admitted to the home since the last inspection. The home has a clear admissions policy and the inspector was informed that the manager would carry out an assessment of any potential new service users needs and also obtain local authority assessment before anyone moved into the home. There were assessment forms in the service users files that were inspected. Donec DS0000011876.V338750.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 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All service users have a plan of care to support them with their needs, however care plans need to be reviewed and reorganisation with clear recording to fully demonstrate that service users needs are met. Staff at the home respect service users rights to be involved and make decisions about their day-to-day lives and service users are supported in this process by staff at the home and also by an independent advocate. Service users are supported to take responsible risks as part of their independent lifestyle. EVIDENCE: Care plans were seen for 3 service users and had information on daily routine, night routine, health, likes and dislikes, continence, personal history, weekly timetable and personal care skills. Care plan files contained lots of information on how the service users wanted to be supported Donec DS0000011876.V338750.R01.S.doc Version 5.2 Page 10 One care plan stated that the service user could at times become aggressive and there was good information for staff on how to manage situations when this happened and there were techniques detailed to reassure the service user. These guidelines were dated 2003, however the inspector was informed that these were still valid and worked well. The home also had an incident log to record any episodes of aggression and this detailed what action staff had taken and if this action had resolved the situation. All of care plans seen were very bulky and contained lots of information about the service user. However much of the information was old and dated back 4 or 5 years. It was not always clear what the current plan was. There was no index in the care plan so information was not always easy to find. The recording in the daily diary did not give any information on what support had been given to service users during the day or night and information recorded was “spent time in dining room” “home” or “spent time in the kitchen” This issue was discussed with the deputy managers. More information is required in daily recording to provide evidence of care delivery. Reviews of care plans regularly take place and dates of reviews are recorded but there is no evaluation of the care plan and no information on how the plan is working for the service users. There was no clear guidance to staff to inform them if there have been any changes to the care plan. All of the care plans need to be thoroughly reviewed and old information should be removed if it is not relevant. It is recommended that the care plan is indexed to provide staff with clear direction of where information is held Service users are actively involved in the decision making process in the home, they are consulted on all aspects of their lives and their wishes were respected and acted upon. The inspector had the opportunity to speak with an independent advocate who supports service users at the home and she confirmed that service users were happy at the home and she said that they would let the manager know if they were not happy. She said that the manager and staff are very supportive and encourage service users to be involved in the day to day running of the home. The inspector was informed that the home held service user meetings every 2 weeks and these were found to be helpful in getting all of the service users involved in the decision making process. Staff know each service user very well and they are able to express their views and wishes to staff who then ensure that their wishes are acted upon. It was clear by observing the staff interacting with service users that they are able to make their own decisions and staff respect their wishes and views. Most of the service users were out at day services or out in the community with staff. Two service users spoken with told the inspector that they were going to the pub for lunch and the Donec DS0000011876.V338750.R01.S.doc Version 5.2 Page 11 atmosphere in the home was relaxed and friendly. They said that they enjoyed living at the home and that the staff were ‘great.’ There were risk assessments in place for service users and these were kept in a separate risk assessment folder. Risk assessments were in place for identified risks and they contained information on the degree of risk and also gave staff information on how to minimise any identified risk. There were also generic risk assessments for the home. However not all risk assessment were regularly reviewed and the inspector recommended that they be reviewed whenever care plans were reviewed or earlier if there had been any incidents. The home had a large number of risk assessments and these gave details of potential risks where there was no evidence that a risk existed and the inspector suggested that the home review the risk assessments in place to see if they were all necessary. Donec DS0000011876.V338750.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 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged and supported to be part of the local community and to be involved in appropriate activities. Service users benefit from support to maintain social contacts and daily routines at the home respect service users rights and responsibilities. Meals at the home are flexible and service users benefit from a healthy diet. EVIDENCE: All of the service users at the home attend day service on varying days of the week and education is provided through the day service to enable service users to develop their independent living skills. The day services provide a range of activities and these including bowling, arts and crafts, cooking, relaxation and trips out to various locations. A service user is a volunteer and works at a local café one day a week and another has a job at a local shop 2 days per week. Donec DS0000011876.V338750.R01.S.doc Version 5.2 Page 13 The home was very busy with service users coming and going and staff were seen to be supporting service users. Two service users spoken with told the inspector they were going to the pub for lunch and on their return they said that they had enjoyed their meal and had a good time. Another service user was supported to go horse riding and another went out to the shops with staff. Service users are encouraged to be part of the local community and are supported to be aware of what events are happening locally, they regularly go shopping, visit local pubs and cafes and attend community events in the local area. One service user accesses the local community independently. Service users are supported to maintain and expand their social networks. Families visit regularly and some service users go to their parents house for weekend stays. Service users are encouraged to invite their friends to their house. Some of the service users at the home have befrienders who have been recruited by the organisation and they visit service users independently and take them out for trips and into the community. Daily routines in the home promote service users independence as much as possible and service users are involved in all aspects of the day to day running of the home. Staff were observed knocking on service users doors before entering and seeking permission from them to enter their rooms. Service users have a key to the front door and also to their own bedrooms. The 2 service users spoken with said that they were happy at the home and liked being involved in decision making. Service users are involved in the planning of meals at their fortnightly meetings and staff provide support to ensure service users have a balanced diet. The home has a 4 week rolling menu with a choice of meal options and service users then choose from this. Service users also enjoy take away meals and also like to go out to eat. The home employs a cook 3 days a week and some of the service users help him to prepare meals. Some of the service users prepare their own breakfast and make their own sandwiches for lunch, while others rely on staff to do this for them. Service users are able to make drinks and snacks at any time. Donec DS0000011876.V338750.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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and service users physical, emotional and health needs are met. The homes policies and procedures with regard to medication provide protection for service users EVIDENCE: Care plans for individual service users gave information on personal care needs and this is offered by care staff of the same gender wherever possible, the home has a policy on cross gender care and staff will respect service users wishes if they have a preference on who they want to give them any personal care. There was information on what support service users required in the mornings and evenings and also information on individuals personal care skills so that staff could offer the correct type of support. The staff team are flexible around the times when service users want their personal support and there are no set routines, however some service users have a daily routine to help with consistency. Donec DS0000011876.V338750.R01.S.doc Version 5.2 Page 15 Service users are registered with a number of different GP’s at a local surgery. Dental checks are carried out through a local hospitals dental service. Eye tests are conducted by local opticians and other health care professionals are accessed through GP referrals. Staff at the home monitor service users health and support service users to access appropriate healthcare professionals and to attend any appointments. Records for any hospital of GP appointments were clear and gave good information on what treatment had been given. The home has clear policies and procedures in place for the receipt, storage and administration of medication and medication records seen were found to be in order. At present the home does not hold any controlled drugs. The home uses a monitored dose system provided by a local pharmacist, although they inspector was informed that they are looking to change pharmacist shortly but medication will still be a monitored dose system. Two of the service users self medicate and appropriate risk assessments are in place. All staff at the home have undertaken training in medication administration procedures. The home has clear information for staff for administering when required medication. Donec DS0000011876.V338750.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by a simple, clear and accessible complaints procedure and the homes policies and procedures protect service users from any form of abuse. EVIDENCE: The home has a clear complaints procedure and this includes timescales for the complaint to be addressed and gives details of how to contact the CSCI. The home keeps clear records of any complaints made and also records responses. There have been 5 complaints since the last inspection and all of these have been recorded, investigated and resolved to the satisfaction of the complainant. Service users spoken with said that they would speak to a member of staff if they were unhappy. Staff members were aware of the homes complaints procedure and said that they would support any service users to make a complaint. Staff have received training in the protection of vulnerable adults and said that they would talk to the manager if they had any concerns, they were aware that they could go above the manager if they felt that this was appropriate and knew who would take the lead in any adult protection issues. Service users spoken to said that they felt safe at the home. Donec DS0000011876.V338750.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 adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a comfortable home enhanced by individually personalised private rooms. The overall service would benefit from decoration to communal areas and refurbishment and repair of the kitchen. The home was clean hygienic and free from offensive odours. EVIDENCE: The inspector toured the home assisted by a member of staff. The inspector looked at 2 service users rooms with their permission and these rooms were personalised and decorated to their tastes with pictures, posters and personal items. Both rooms had good levels of equipment televisions, DVD, CD players and radios. The 2 service users spoken with said that they were very happy with their room and they said that they had everything that they needed. The home was generally well maintained and had good furniture in the communal areas, however there had been a leak in one of the bathrooms, which has caused the ceiling in dining room to become wet. This has meant Donec DS0000011876.V338750.R01.S.doc Version 5.2 Page 18 that the lounge was out of action for a short time. On the day of the inspection work was being carried out to repair this problem. When touring the building it was evident that the communal areas were showing signs of age and wear and staff agreed they were in need of some decoration. The organisation has recently employed a new handyman and it was hoped that he would be able to decorate some of the communal areas. The kitchen was one area which was in need of attention, there were missing doors and some drawer fronts were missing. The inspector was informed that these had been repaired but kept breaking as the kitchen was old. Work is due to commence shortly on 3 new purpose built homes in the grounds and it is hoped that service users will be able to move in to this new accommodation next year. However the home still needs to have a programme of repair and refurbishment for the existing home to ensure that service users live in a home that is kept in good repair and that is reasonably decorated. The laundry has washable floors and walls and contains an industrial washing machine that can wash clothing at suitable temperatures and there is an industrial tumble drier. Some service users are able to use the laundry independently while others require staff support. The home was kept clean and tidy and there were no offensive odours. Donec DS0000011876.V338750.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, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff who are employed at the home have the competencies and qualifications required to meet service users needs and service users benefit from being supported by dedicated and qualified staff. Service users at the home are protected by the home’s recruitment procedures and service users are supported by qualified and trained staff who receive regular supervision. EVIDENCE: There is a good staff mix at the home and there are 17 permanent care staff employed at the home. All staff are encouraged and supported to undertake NVQ training. Currently the home has 6 members of staff who have completed this and 2 are undertaking this qualification. The home is part of Elizabeth Fitzroy Support and recruitment is robust and whenever possible service users are involved in the interviewing process. Three recruitment records were inspected. The files seen by the inspector contained all of the required information, including application forms, Donec DS0000011876.V338750.R01.S.doc Version 5.2 Page 20 photograph, passport, birth certificate, two references and POVA and criminal records bureau checks. Volunteers who work at the home have also undergone robust recruitment checks. The organisation has a training co-ordinator who arranges a rolling training programme and this includes mandatory training for all staff employed. Training is provided in moving and handling, fire safety, medication, first aid, health and safety, food hygiene and infection control. Staff undertake an induction and foundation course in line with the Learning Disability Awards Framework (LDAF) and staff members spoken with confirmed that they had received a good induction and said that if they identified any training courses that were relevant to the service users they support, then this could be organised for them. Staff receive regular supervision from their line manager and this is recorded and kept in staff files. The inspector was able to see records of supervision sessions and there was a list of dates for staff supervision in the manager’s office. Staff members spoken to confirmed that they receive regular supervision. Donec DS0000011876.V338750.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 & 42 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The homes manager is not yet registered with the CSCI despite being in post for over a year and the slow return of the AQAA (Annual Quality Assurance Assessment) does not evidence that the service is well managed. Service users, relatives and other interested parties are consulted about the running of the home. The health safety and welfare of service users and staff are promoted and protected. EVIDENCE: The manager of the service was not available on the day of the inspection, however the inspector did speak with the manager on the phone the day after the inspection. She has been in post for some time but is not yet registered with the Commission for Social Care inspection. She informed the inspector that an application form has been submitted and she is waiting for her Donec DS0000011876.V338750.R01.S.doc Version 5.2 Page 22 application to be processed. The home was required to complete an Annual Quality Assurance Questionnaire prior to the site visit to the home, however this was not returned on time and this reflects on the management of the service. The inspector spoke with the deputy manager of the home and explained the importance of this document and the need for it to be returned to the CSCI on time. Each resident has a key-worker who works closely with the service user concerned and they help service users make decisions about the service provided for their particular key resident. Service user, relatives and care managers are included in yearly care reviews and these reviews are used to monitor how the home is meeting its aims and objectives. There are regular staff and service user meetings held and minutes of these meetings are kept by the home. Regular monthly regulation 26 visits are carried out and this is another opportunity to obtain service users views. There are policies and procedures in place to ensure safe working practices in the home and all care staff undertake statutory training, which includes health and safety, food hygiene, first aid and manual handling. The fire logbook was inspected and all required testing had been carried out. Certificates were available for annual testing of equipment and services. Donec DS0000011876.V338750.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 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 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 3 X X 3 X Donec DS0000011876.V338750.R01.S.doc Version 5.2 Page 24 No 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 YA6 Regulation 15(1) Requirement The registered person must ensure that service users’ care plans give staff and service users clear information on how the individual service users needs are to be met. The registered person must ensure that there is a plan of refurbishment and decoration for the home to ensure that the home is kept in a good state of repair and that it is reasonably decorated. Timescale for action 01/10/07 2. YA24 23(2)(b) & (d) 21/08/07 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 Donec DS0000011876.V338750.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Donec DS0000011876.V338750.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!