Inspection on 28/11/06 for Eight Ash Court

This inspection was carried out on 28th November 2006.

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

Eight Ash Court 22/02/06

Eight Ash Court 13/10/05

Eight Ash Court 01/03/05

Eight Ash Court 07/09/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Eight Ash Court Halstead Road Eight Ash Green Colchester Essex CO6 3QJ Lead Inspector Tim Thornton-Jones Unannounced Inspection 28th November 2006 09:00 Eight Ash Court DS0000017809.V320807.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 Eight Ash Court DS0000017809.V320807.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. Eight Ash Court DS0000017809.V320807.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eight Ash Court Address Halstead Road Eight Ash Green Colchester Essex CO6 3QJ 01206 710366 01206 710366 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 Pelandapatirage Gemunu Susantha Dias Mrs T Cheung, Mr W K Cheung Mrs Jacqueline Kennedy Care Home 12 Category(ies) of Learning disability (12), Physical disability (3) registration, with number of places Eight Ash Court DS0000017809.V320807.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 12 persons) Two named persons, under the age of 65 years, who require care by reason of a learning disability, who also have a physical disability, who have resided in the home since April 2002 One male person, under the age of 65 years, who requires care by reason of a learning disability, who also has a physical disability, whose name was made known to the Commission in June 2003 The total number of service users accommodated in the home must not exceed 12 persons 22nd February 2006 3. 4. Date of last inspection Brief Description of the Service: Eight Ash Court is a care home providing personal care and accommodation for twelve individuals, with learning disabilities, of whom three named individuals have physical disabilities. It is owned by Mr R Dias and Mr & Mrs Cheung. The home is located in Eight Ash Green, within a walking distance from local amenities. All of the home’s rooms are single, none have en-suite facilities. Each of the two units have separate kitchen, laundry and communal areas. The care home was registered prior to the commencement of the Care Standards Act 2000 and the requirements of the National Minimum Standards. The service ‘pre-existed’ and therefore the standards associated with the premises comply on this basis only. Eight Ash Court DS0000017809.V320807.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The range of fees for care and accommodation were confirmed by the manager as being between £ 117.00 and £180.00 per day. This inspection concluded that the overall service provided to those living at the home was good. Some aspects of the service have been rated as excellent. The environment was homely and comfortable and positive effort is made by staff to encourage service users to be as relaxed and ‘at home’ as possible. The manager has a clear commitment to a ‘person centred’ approach to care planning and this was reflected within the written plans, practice of care staff and the way records were compiled and maintained. Mrs Kennedy has reviewed to shortfalls highlighted at the previous inspection and these are now resolved indicating a clear commitment to improvement and development of practice and quality outcomes for service users. Healthcare arrangements were well managed and support from various healthcare professionals was evident. This showed a positive commitment to multidisciplinary working. The home has a very good commitment to staff related matters and based upon the recruitment practice, induction, training and supervision of care staff this area of the homes activity was excellent. Service users are helped to access the community to do the things they have said they wish to do as far as possible. This includes the use of local amenities for social, leisure and educational support. The homes approach to concerns and complaints, together with the ethos of safeguarding vulnerable adults supports a safe environment. What the service does well: • • • • Maintains a welcoming and homely environment. Staff recruitment, induction, training and supervision. Person centred approach to care management and assessment. Overall good professional attitude and practice of staff. Eight Ash Court DS0000017809.V320807.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. Eight Ash Court DS0000017809.V320807.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 Eight Ash Court DS0000017809.V320807.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): Standards 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • Service users benefit from information they need to make an informed choice about the home. EVIDENCE: The home has a Statement of Purpose available upon request. A Service Users Guide, which is individual to each SU, has been produced in an ‘easy read’ and symbol format for service users. Other information about the service is available and this includes a video guide. No service users have been admitted to the service during the period since the previous inspection however, the arrangements for pre-admission assessment and transition support were in place. The service has an admission procedure that includes the receipt of a needs assessment undertaken by the ‘care manager’, normally a local authority or healthcare professional, who would be responsible for the planned move of the prospective service user. In addition, the service would complete an internal Eight Ash Court DS0000017809.V320807.R01.S.doc Version 5.2 Page 9 information gathering process to assist with the formation of an initial plan of care. Consultation with the service user and their family/advocates forms part of this process. The service provides a 3 month trial period for both the home and the service user to decide how successful the arrangement has been and to decide if the person is to remain living at the home. At the point of confirming that the person is to continue at the home a terms and conditions of residence are completed, this forms part of the service users guide. Eight Ash Court DS0000017809.V320807.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): Standards 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • Service users benefit from the homes arrangements for care planning and way decisions are made on a day to day basis to support service users as part of an independent lifestyle. EVIDENCE: Information was gathered from discussion with staff, including the manager and inspecting records. Discussion with service users was limited on this occasion as most were out of the home following various activities. Information available showed that service users attended a variety of organised day activity opportunities including a day centre, further education classes (music and exercise) and two further service users are shortly to attend a local college to view and consider other learning schemes. Social and leisure opportunities for service users also include ‘bouncability’, cinema, gateway social club, swimming and aquasprings twice weekly. Eight Ash Court DS0000017809.V320807.R01.S.doc Version 5.2 Page 11 A Key worker system used within the home has been further developed and now enables relatives to contact the designated key worker directly rather than always initially referring to the manager. This is positive for the service user since the carer (key worker) needs to remain well informed about the current issues that impact upon the persons daily life. The arrangement is also positive for the relative to be reassured that the person has a carer coordinating the care of the person. Service user care plans were sampled. One example showed that assessments had been recently updated. These included moving and handling and health and safety issues linked to the persons risk of epileptic episodes. Various other assessment data was available and up to date. The care plan decisions linked to all aspects of the person’s welfare including personal care and healthcare. The service user within this sample is diagnosed as epileptic and the plan shows that the person visits a nurse specialist 3 monthly. A record of the seizures the person has was evident. The supporting records were reflective of a pro-active and detailed approach to monitoring the frequency, severity and aftercare required. This demonstrated the plan informed future care and planning for the person and links to specific healthcare and support from other professionals. Various other recording ‘charts’ were in operation for this person. The plan showed a useful communication, likes and dislikes sheet, showing key words and phrases that the person expressed, and what they mean for the individual. This demonstrated a person centred approach to communication. The daily recording within the plan by staff has been further developed by separating the recording into useful sections such as ‘Social Diary’, GP/Consultants diary, and ‘personal diary’, which seems to cover all the necessary areas. The quality of the recording has improved and developed. From the sample seen, this demonstrated that the recording was objective and factual. Accidents recorded within the daily notes cross referenced with specific accident records although there is potential to streamline this approach to reduce the range of recording undertaken. All primary healthcare services that are required to support the person are accessed. For some service users a dentist visits the home to undertake a routine check. This arrangement is made to reduce any potential anxieties that individuals may have. If treatment is required, a visit to the surgery is arranged. Records are clear and accessible. It was pleasing to note that details included within the ‘personal hygiene and dressing’ section of the plan included advice about the persons preferences Eight Ash Court DS0000017809.V320807.R01.S.doc Version 5.2 Page 12 regarding clothes, makeup and accessories. commitment to a person centred approach. This again demonstrates a A further example of a care plan was viewed. The structure and layout was similar but the individual data was diverse and linked directly with the person and their care needs. This example indicated a good example of well planned and maintained person centred plan. In discussion with staff, they were able to demonstrate a good understanding of the care plan and showed a good level on understanding of the methods specified within the plan. In observation of care staff practice, this again reflected the way in which the plan had set out methods and identified outcomes. Eight Ash Court DS0000017809.V320807.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • Service users benefit from the homes arrangements to support opportunities to access the community. • • • Service users benefit from an open and flexible approach to visitors and maintaining links with family and friends. Service users benefit from the manner in which support is provided by staff. Service users benefit from catering arrangements provided. EVIDENCE: Based upon information available service users do take part in age, peer and culturally appropriate activities. Activities are occupational, social and leisure Eight Ash Court DS0000017809.V320807.R01.S.doc Version 5.2 Page 14 and educational focussed. Some service users attend an organised day activity centre and it is understood this provides a range of activities. None of the service users participate in paid employment or work related schemes in view of their disability. Staff are identifying ways in which service users can take part in educational based courses, designed specifically for adults with disabilities. Service users do access the community in a variety of ways. The inspection was able to identify that service users use, with support, a good range of entertainment facilities both for people with and without disabilities. All recently admitted service users receive a holiday that is paid as part of the contractual arrangements, however, existing service users finance their own holidays. Service users finances held in safe custody by the home were not inspected as part of this visit. The home has a flexible visiting policy, described as open in the same way that relatives would visit family in their own home. Records indicated that visitors were regular and that good communication has been maintained between the home and families. The ‘rules’ within the home are kept to a minimum to maximise flexibility and choice. Where rules do apply to some service users these are well documented and subject to risk assessment. The style of communication between carers and service users was informal and casual but retained respect in that none of the service users at home during the inspection was referred to, for example, by a ‘nick name’ or other title or description. Service users were enabled to use both their own private room and communal areas in a proportionate balance and in a discreet manner. The garden is accessible and is well maintained. The catering arrangements are well planned with a proposed menu based upon the preferences of service users. Staff who care for service users also undertake the cooking and other food preparation and as such have attended a food hygiene training. Appropriate recording is undertaken to ensure that each service user receives a balanced and nutritional diet. Appropriate arrangements are in place to support service users who require assistance with eating. Eight Ash Court DS0000017809.V320807.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 benefit from the care principles and practice of the service in maintaining dignity, independence and control over their lives. • Service users mainly benefit from the healthcare arrangements within the home. • Service users benefit from the arrangements to maintain and secure prescribed medicines on behalf of service users. EVIDENCE: The prescribed medicines system used at the care home is a monitored dosage system. The type, dosage and frequency of medicines was well recorded within the care plan, and the recording is well maintained for individual dosage in the medicine administration record (MAR). The Manager has included a recent photograph of each service user to each of the blister packs as a second reference for carers to check as a safeguard. The medicines were securely held. Consent to medicines being held by the home on behalf of service users was evident. Eight Ash Court DS0000017809.V320807.R01.S.doc Version 5.2 Page 16 A picture of the visiting GP and Community Nurse was located in the hallway so that service users could recognise the person when they arrive at the home. The service user plans gave very good descriptions about the way that service users are guided, and supported in both their personal and healthcare. Some of the requirements are detailed to reflect the moving and handling requirements of some service users who have a physical disability. The care plans for each individual detail the type and level of support each person needs to achieve adequate personal hygiene, with emphasis on the individual undertaking as much of the task for them as possible. This reflects the person centred approach the home has taken with all aspects of the care process and enables and empowers service users to take as much control as possible. Service users have the aids and adaptations they require to be as mobile as possible and care planning remains ongoing to ensure the equipment is appropriate to meet their changing needs. The care plans sampled did not specify routine healthcare screening within the healthcare arrangements and this is recommended. Eight Ash Court DS0000017809.V320807.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • Service users benefit from the homes arrangements regarding the receiving and investigation of complaints. • Service users benefit from the homes safeguarding adult arrangements. EVIDENCE: A suitable complaint procedure written in ‘easy read’ format and symbols was displayed on the notice board in the entrance hall to the home. The Manager confirmed that no complaints had been investigated by the home during the period since the previous inspection. CSCI have not received any complaints, concerns or allegations about this service during the same period. The Manager demonstrated a good understanding of POVA issues and clear procedures were in place. No referrals by the home have been made under safeguarding adults during the period since the previous inspection. The home has a copy of the local authority procedures regarding safeguarding adults and internal arrangements link to this in a satisfactory way. Some staff have received suitable training in protecting vulnerable adults. Eight Ash Court DS0000017809.V320807.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): Standards 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • The environment is maintained in a homely and comfortable manner, taking account of service users’ privacy and comfort. EVIDENCE: The home comprise of two bungalows. Both dwellings were visited and found to be in good order in terms of decoration and furnishings. Both dwellings have rooms that were individual to each service user in terms of gender and interest. One bungalow accommodates a higher proportion of people who have a profound physical disability and the environment reflected this. Various items of moving and handling equipment were available. There were no obvious health and safety hazards noted in either dwelling. Access to the building is adequate for wheelchair use. Eight Ash Court DS0000017809.V320807.R01.S.doc Version 5.2 Page 19 The areas visited in each dwelling were clean and there were no unpleasant odours detected. Both were welcoming and had a homely feel. The external areas were well maintained being mainly laid to lawn. The front of the site is laid to hard standing for vehicular use. Eight Ash Court DS0000017809.V320807.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34, 35 and 36. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. • Service users benefit from the homes arrangements with recruitment, induction, training, deployment and supervision of care staff. EVIDENCE: The inspection process included the homes approach to recruitment, supervision, training and deployment of care staff. In addition to records being inspected, staff were spoken with and discreetly observed undertaking a variety of tasks with and without service users. The home has a very good commitment to training and development of carers. The records indicated that carers have been involved in both national Vocational Training (NVQ) and the Learning Disability Award Framework (LDAF) training and induction approach. Staff spoken with were enthusiastic about training and all stated they wanted to progress with further skills development. The total number of care staff stated to be employed was 18. Of these 9 are qualified to NVQ level 2 in care (50 ) with a further 6 carers working toward Eight Ash Court DS0000017809.V320807.R01.S.doc Version 5.2 Page 21 the qualification. positive. Six carers are working toward NVQ level 3, which is very Fifteen carers have completed the LDAF induction standards with 2 working toward completion. One carer has recently enrolled on the learning course. The files examined were very well organised and comprehensive. All recruitment requirements were met and of those files sampled further information about past experience and training was evident. The arrangements for the control and organisation of staff training and development was very good with each staff member having a training and development profile taking into consideration previous experience and training together with presenting needs and development requirements. Action plans were evident. The supervisory approach was examined via sampling and was found to reflect very good, proactive practice with supervisory agreements in place and all supervision sessions up to date. The content of supervision sessions reflected a sound professional approach. In discussion with the Manager, Mrs Kennedy, she was able to clearly demonstrate the link between knowledgeable and trained carer staff with positive outcomes for service users and the manner in which these factors are developed in the work setting. The commitment, approach and organisation of training and development were excellent. Staff were observed to frequently work in a way that was empowering and gave service users positive choices and where service users struggled with the choice available, staff responded appropriately with an alternative informed choice. Carers demonstrated a professional and committed approach to the support provided, however, care at times must be taken to ensure that language used remains appropriate at all times. One carer was overheard to sometimes respond to service users in a way that was not always age appropriate such as for example responding to a service user in her 40’s saying ‘good girl’, as an encouraging gesture however, this should not be overstated since overall the practice was very good. Staff were relaxed and interacted with service users appropriately. Staff spoken with stated they felt very supported and that an open and communicative ethos operated with all the care team, including managers and supervisory staff. A key worker system was in operation and staff spoken with demonstrated a sound understanding of how this worked in practice and their role within the process. Eight Ash Court DS0000017809.V320807.R01.S.doc Version 5.2 Page 22 The homes assessment of the staff requirement to support service users was 548.84 based upon a method recommended by the Department of Health. The deployment of care staff taken from the homes deployment record (sample) indicated that the deployment was 589.50. This exceeds the assessed figure, however does not include the tasks that care staff undertake as not part of their care duties such as cooking, cleaning and laundry tasks. The additional hours of approximately 41 hours were considered adequate by the Inspector to account for the additional non-care related tasks throughout the week. Eight Ash Court DS0000017809.V320807.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): Standards 37, 39, 41 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • Service users benefit from a service that is well managed. • Service users mainly benefit from the homes approach to quality assurance and monitoring. • Service users benefit from the homes record keeping practice. • Service users benefit from the homes approach to health and safety. EVIDENCE: The Manager is qualified and experienced to operate the home and maintains skills and knowledge periodically. The ethos and leadership within the home is very positive as validated by care staff and by discussion of professional practice and methodology with the Inspector. The manager demonstrated a committed and reflective management style and showed through the diverse Eight Ash Court DS0000017809.V320807.R01.S.doc Version 5.2 Page 24 ways of obtaining training for staff and a commitment to quality outcomes for service users that Mrs Kennedy exceeds the minimum requirements. Her overall performance is excellent. The quality assurance and monitoring was reviewed. The Manager has redesigned the questionnaire format and a full discussion was held between the manager and inspector regarding methodology, data collection and analysis. Service users, relatives and other stakeholders questionnaires have been distributed and returned. These results were presented as objectives and have subsequently been published via a report to CSCI and a newsletter to stakeholders. The recording forms/questionnaires would benefit from further development to ensure ‘easy read’ and assistance to include improved response range rather than the current yes/no response. For example the range could include ‘sometimes’ or ‘not often’ or similar. Based upon the various records seen and access to the homes policies and practice procedures all were well maintained, accurate and reflective of the homes objectives and care outcomes. Daily notes are improved. The manager had ensured that health and safety matters are up to date and well maintained. The last fire drill, emergency lighting check, portable appliance check and gas safety check were all current. The last formal visit of the home by the Person in Control was October 2006 and therefore current. The last visit by the Environmental Health Officer was 23rd October 2006. There were no concerns expressed. Eight Ash Court DS0000017809.V320807.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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 4 X 3 X 3 3 X Eight Ash Court DS0000017809.V320807.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. Refer to Standard Good Practice Recommendations Eight Ash Court DS0000017809.V320807.R01.S.doc Version 5.2 Page 27 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 Eight Ash Court DS0000017809.V320807.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. 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