Inspection on 30/06/08 for Ebbsfleet House

This inspection was carried out on 30th June 2008.

CSCI found this care home to be providing an Adequate service.

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

Ebbsfleet House 20/06/06

Ebbsfleet House 24/01/06

Ebbsfleet House 07/07/05

Ebbsfleet House 19/01/05

Ebbsfleet House 14/04/04

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Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

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Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Ebbsfleet House Ebbsfleet House Tubbs Lane Ramsgate Kent CT12 5DH Lead Inspector Julie Sumner Unannounced Inspection 30th June 2008 09:30 Ebbsfleet House DS0000037202.V365311.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 Ebbsfleet House DS0000037202.V365311.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. Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ebbsfleet House Address Ebbsfleet House Tubbs Lane Ramsgate Kent CT12 5DH 01304 613004 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) ebbsfleet@hqls.org.uk www.hqls.org.uk High Quality Lifestyles Ltd vacant Care Home 5 Category(ies) of Learning disability (0) registration, with number of places Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category 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 category: 2. Learning disability - LD The maximum number of service users who can be accommodated is: 5 20th June 2006 Date of last inspection Brief Description of the Service: Ebbsfleet House provides support and accommodation for five service users with learning difficulties. The home is a detached property in a large expanse of grounds and has been adapted to meet the needs of the current service users. There is parking to the front of the building and a large enclosed garden to the rear. The main body of the home accommodates four service users with a self-contained area known as the cottage accommodating the fifth person. Although the home is not in a central residential area, transport is available and outings and shopping trips are regularly undertaken following completion of risk assessments. The fees for support from the home are set during the assessment period and are very individual to the needs of the service user, depending on the level of support required and the staffing numbers provided. Fees can therefore range from low to higher thousands of pounds following the appropriate assessments. Information on the home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address for the home is ebbsfleet@hqls.org.uk and for the company is www.hqls.org.uk. Ebbsfleet House DS0000037202.V365311.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 the people who use this service experience adequate quality outcomes. The star rating has fallen from 2 star (good) since the last inspection. This report is based on information received about Ebbsfleet House including an annual quality assurance assessment (AQAA) completed by the manager and an unannounced visit to the home lasting just under 5 hours. Information was gathered for this inspection in a variety of ways both prior to and during the visit to the home. We gave the manager time to collect important information that was not available during our visit so it could be included in this report. The visit included talking with the people living in the home, the manager and staff. General observations were made during the day of how people are supported. There was a tour of the building and various records were inspected. The people living in Ebbsfleet House were able to participate a little in the inspection by meeting us and joining in with conversations about their lifestyle. At the time of this inspection visit the manager was not registered with the commission for social care inspection. What the service does well: The people living in the home are assessed regularly to make sure the service is meeting their needs. People are supported to have an active lifestyle. They are encouraged and supported to do as much as possible for themselves. People are supported with their communication and challenging behaviour to increase the opportunities available to them. There is a person centred support team and a consultant psychiatrist employed by the company to provide direct support to the people living in the home. The home meets the physical and healthcare needs of the people who live there. There is input from specialists and local GP’s. Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 6 There is a good range of training from person centred planning to managing challenging and potentially destructive behaviour with positive behaviour support. What has improved since the last inspection? What they could do better: The service needs to expand and develop the information in the AQAA to give a better picture on how the service is progressing. They need to tell us more about their shortfalls and how these are going to be addressed. They need to tell us their plans for the future and how they are improving the service for the people who live at Ebbsfleet House. The manager of the home needs to register with the commission. The home has got into a very poor state of repair due to subsidence and a breach in damp proof course. There are cracks in the walls, some windowsills are rotten and there are damp patches with visible damage in ceilings and walls at the front of the building. The company are addressing this and have employed a new maintenance team. This was discussed at a meeting with the providers after the inspection visit. They are going to give us the maintenance programme plan as soon as possible. Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 7 Parts of the home did not smell fresh. We discussed the action the manager was taking to manage incontinence. Some new furniture has been ordered and the cleaning products are being reviewed. The fire risk assessment could not be found in the home. There was some damage to one of the doorframes so that the fire door could not close. They need to contact the fire safety officer and make sure the home has a fire risk assessment. We wrote to the responsible individual for High Quality Lifestyles soon after our visit to make clear the urgency of attention needed to improve the building. The responsible individual responded to us with a plan of action. 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. Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 8 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 Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 9 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 good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken. EVIDENCE: There are currently three people living in the home. No new people have moved into the home since the last inspection visit. Ebbsfleet House DS0000037202.V365311.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): People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service recognises the right of individuals to make their own decisions and support people in a positive way. The person centred plans are not all used as working documents and do not consistently reflect the support being given. EVIDENCE: Two person centred plans were viewed and discussed with the manager at the visit. Individuals have had a little input into the compilation of these but not recently. Both plans that were looked at were out of date. The names of people who were important including who the manager of the home is and who the key worker is were incorrect. The plan stated activities that were no longer carried out and overall appeared not to match what was actually happening in the home. The manager said they were going to be reviewed. One of the senior support workers has been attending training in person centred support with the Tizard centre. He is currently working on a person centred plan with one of the people living in the home. Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 11 Discussion with the senior management after the site visit told us that the reviewing process was well under way, and that reduction of challenging behaviour was a priority. Within this support framework, risk and choice is well supported. We were also told that one personal plan had been fully reviewed with their involvement and all the people that are important to them. The company have a risk assessment format and risks are also assessed as part of the positive behaviour support analysis. There are clear guidelines for staff and these also need to be included in all the person centred plans. Individuals have key workers. The manager explained that one-to-one meetings are held to discuss what individuals want. One of the people living in the home has an independent advocate. One person with communication difficulties has been referred to the speech and language therapist and a programme of support is being developed. Staff talked about their role and the support of people living in the home. They complete the daily log books. These are used as reference to collate behaviour, general activity and any medical observations. A sample of these was viewed and records were up to date containing some good basic information. Ebbsfleet House DS0000037202.V365311.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 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home are involved in meaningful daytime activities of their own choice and participate in the day to day running of the home. People have the right support to get out and about into the community. EVIDENCE: Activities are recorded in the daily log sheets. A sample of these were viewed and indicated that people get out of the house daily for walks or drives. There are groups and college courses that individuals attend. On the day of the visit one person stayed in to carry out household chores, one person went to college and one person went out to do some personal shopping and go for lunch. It was possible to spend a little time with one person before he went out and another person spoke about what he likes to do when he got back. Both behaved very positively about their lifestyle. Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 13 Staff have supported people to reduce their behaviours that are challenging and that have previously prevented their opportunities to have a full and active life. We saw evidence that people who seldom went to busy places, like café’s were being supported successfully. A clear plan to reduce challenging behaviour was in place for each individual, and this had resulted in total reduction of physical interventions for challenging behaviour, which is a major success. The home have 2 cars, one for general use for taking service users out and one belongs to one of the people and is leased under the Motability scheme. People are supported to maintain relationships with their families. One person was at home with his parents at the time of the inspection visit. The manager said the families keep in touch and he keeps them up to date with events at the home. The people living in the home have free access to the kitchen and can access refreshments throughout the day. Meals are made at flexible times around the planned activities. Individuals participate in the menus choosing what they want to eat. Ebbsfleet House DS0000037202.V365311.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 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Personal and health care support is responsive to the varied and individual needs and preferences of the people who live in the home. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) given to us, said that “the home provides written guidance for staff to follow, based upon observations of how service users prefer to be supported. An individualised approach is taken with each individual in all aspects of their support.” Staff were observed talking respectfully to individuals and taking their lead with choice of activities and support individually. The home have records for monitoring behaviour and observations. There was a part of the person centred plan that was called ‘health action plan’. This part had some guidelines for what staff need to do to support individuals health. The health action plan included what medication each person was on, having the medication checked, whether they needed support with diet, cleaning teeth and visiting dentist. Appointments are logged in the Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 15 homes diary. The people are registered with a local GP and have access to a specialist dentist. There was a discussion with the manager about designing the health action plan to increase the person’s own awareness of their health and how staff can support them to do this. The manager said he would do this. Support is also given by the local learning disability team for speech and language, occupational therapy and psychology when required. Each person is reviewed monthly by the organisations consultant psychiatrist. The medication in the home has been significantly reduced in the last year as staff have supported individuals with their health needs and with positive behaviour support. The manager has his own medication auditing system and this has been effective at picking up errors, which have been reported appropriately. The last audit was carried out six weeks prior to the visit and it was noticed that there was an error in the administration record. The manager said that there had been some situations in the home that had been a priority and taken up his time. The manager said that it was his intention to resume carrying out audits more frequently. He also said that he intended to review the administration procedure so that another member of staff checked medication as it was being given to prevent errors occurring. Since the visit these changes have both been put into place. Ebbsfleet House DS0000037202.V365311.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 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home are supported to voice their concerns and the procedures in the home protect people from abuse. EVIDENCE: There have been no complaints about the service provided. The company has produced a service user friendly complaints procedure. The complaints procedure has been revised to include timescales although a copy was not available in the home. The manager said that he holds one-to-one meetings with the people to give them an opportunity to express their views. One person also has the support of an independent advocate. The company have recently reviewed the safeguarding adults training to make sure that it is giving the staff the right skills and knowledge. The training takes place over a full day. All staff have received safeguarding training. The AQAA indicates that staff take a proactive approach with the people living in the home with regards to complaints. Staff work with individuals and monitor behaviour so that they can recognise when a person is unhappy and take appropriate action. There has been a commitment to reduce restrictive physical interventions and this has been successfully implemented. This protects people from physical abuse. Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 17 The company provide a programme of training for staff to manage challenging and potentially aggressive behaviour. This is ongoing with new staff receiving the training and more experienced staff having refresher courses again. Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The current physical environment does not provide a pleasant place for people to live. EVIDENCE: The home is situated in a rural setting. It is spacious inside. Each person has their own bedroom. Two bedrooms have ensuite toilets. There is an activities room with sensory equipment. The staff have been attempting to decorate the home with pictures and ornaments with the people living there to make it more homely. Unfortunately many of these had been removed and destroyed by one of the people living in the home. On the day of the inspection visit, parts of the home were in a bad state of repair. The AQAA did not truly reflect the state of the home and grounds. The only improvement noted in the AQAA was planned for developing the grounds. The manager was open about what was needed during the inspection visit. Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 19 There had been some movement in the building. One of the outer walls had been reinforced. The manager said there were plans to demolish the part of the building that adjoined the main building at the point of this wall. The movement had caused some internal damage. There were several cracks in the walls. The kitchen doorframe had changed shape and the door, which is a fire door, would no longer close. There was damage from damp on walls in parts of the home. Some of the walls had been treated but the damp was showing through again. Some of the windowsills were rotten. One of the people living in the home was mopping some of the floors. All the floors are washable. There is no carpet apart from on the stairs. The kitchen appliances had protective surrounds to safeguard the people living in the home. They were effective but not attractive in a homely way. The manager said that the area manager had commented on this at the last visit and there was an action to consider alternatives. The kitchen units had some damage. The maintenance team who were given full responsibility for the upkeep of the home have now all left employment. This has delayed the improvement programme. The company have now recruited a new maintenance team. The responsible individual said that they would give us the maintenance plan as soon as it is developed. One of the people living in the home had ripped the wiring outside the day before the inspection visit, so that the outside lights and a telephone was not working, although there was a separate phone that did still work. The manager explained that the home did suffer some damage as a result of people’s behaviour at times and this accounted for some of the damage seen on the day of the visit. The staff had been working on the outside areas. One person has a separate garden and the fence had been painted. Another part of the gardens has different shelters that have been provided to meet a person’s needs and one of these had been decorated. The laundry was small but contained good equipment, including an industrial washing machine. The flooring was damaged and was due to be replaced. The part of the home that provides separate accommodation smelled strongly of urine and also disinfectant. The manager stated that the sofa was being replaced as this was part of the cause of the odour from incontinence. This is currently being addressed by a behaviour management programme. Additional advice had also been sought from the continence advisor. The manager and staff said that they didn’t think the cleaning products the company used were effective. The AQAA states 2 staff have attended infection control and training has continued for the other staff. A recommendation has been made to use Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 20 the Department of Health guide to “essential steps” to assess the current infection control management. The responsible individual wrote to us and explained that the insurance company have been informed of the structural movement. They are awaiting a full structural survey to determine what remedial work needs to be done. The effects of the damp will be repaired following this. Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 21 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): People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home have confidence that the staff will support them to meet their needs. EVIDENCE: The home now has a full staff team and do not need to routinely use agency staff as before. The staffing level has been reviewed in line with the current funding and service user need. The manager and three staff work on each shift. In addition to this a forth member of staff works flexibly so that each person can go out and pursue their chosen lifestyle. There is one waking night staff and one sleep-in. Staff were happy to talk about their roles and were observed to be positive in their interactions with the people living in the home and each other. We saw two staff files. There was evidence that the safeguarding checks had been made but not all the documentation needed was in one of the files in the home. All the original staff documentation is kept at the head office. The manager said that he would make sure all contents were included in each of Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 22 the staff files in the home. The company uses the skills for care common induction standards and has a company induction that staff attend externally. The company have a training manager who provides a range of training for staff to access. Staff training is ongoing. Seven out of twelve members of staff had either completed an NVQ or were working towards one. Specific training is given to staff in all aspects of person centred support and autism. The manager had a timetable of staff supervision and in these recent one-toone meetings staff had identified training that they would like to attend which was attached to the notice board. One person is attending training in person centred planning at the Tizard Centre, which he said he was enjoying. Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 23 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager has a good understanding of the direction the service should go from the service users perspective. The documentation in the home is not well organised to enable effective management of the service. EVIDENCE: The manager has several years of experience supporting people with learning disabilities and challenging behaviour in a variety of settings. He demonstrated a sound knowledge of individual needs and how to guide the staff to support the people living in the home. He has been manager of the home for around a year. He has not applied to be the registered manager yet. He said that it is his intention to become the registered manager for the home Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 24 and has the application forms. The manager initiated his registration with CSCI shortly after this visit. The company have employed an area manager who has been carrying out the monitoring visits. The most recent report stated that the environment is in a poor state of repair, needing decorating in various areas and cleaning. Damp patches were identified and it stated that the home has structural issues, which will need addressing in the long term. The responsible individual wrote to us in response to our letter and has given us the company’s plans for action. Questionnaires were developed last year for service users as part of the quality monitoring processes. They have been used in the company but feedback suggested that they were not suitable and they are being redesigned by the company quality and training director. The manager said that he would design his own relatives’ surveys and send them out to the parents. The manager said he would prioritise what needs to be done and write a development plan for the home. The dates of servicing and maintenance of the building were requested to make sure that checks for the safety of the building were being carried out. Not all the certificates were available in the home. The dates were not included on the AQAA for reference either so these were requested to be given following the visit. The fire risk assessment was not available. We discussed that the manager must contact the fire safety officer and make sure the home has a fire risk assessment. In response to the inspection visit outcomes, the manager has contacted the fire safety officer and organised for the kitchen fire door to be repaired. The office was not very well organised and the manager had difficulty locating some of the documentation requested on the day. All the staff have all the health and safety training that they require and the wellbeing of service users is protected. Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 25 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 4 ENVIRONMENT Standard No Score 24 1 25 x 26 x 27 x 28 x 29 x 30 1 STAFFING Standard No Score 31 x 32 3 33 x 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 3 13 4 14 x 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 2 x 2 x 2 x x 2 x Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 26 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. 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 Good Practice Recommendations Need to use the Department of Health guide to “essential steps” to assess the current infection control management. Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 27 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 Ebbsfleet House DS0000037202.V365311.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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