Inspection on 30/01/07 for Emscote House

This inspection was carried out on 30th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Emscote House 21/03/06

Emscote House 13/10/05

Emscote House 08/03/05

Emscote House 01/12/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Emscote House Emscote Drive Wylde Green Sutton Coldfield West Midlands B73 5NE Lead Inspector Gerard Hammond Unannounced Inspection 30th January 2007 09:00 Emscote House DS0000016726.V328911.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 Emscote House DS0000016726.V328911.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. Emscote House DS0000016726.V328911.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Emscote House Address Emscote Drive Wylde Green Sutton Coldfield West Midlands B73 5NE 0121 382 1463 0121 382 1463 emscotehouse@normanlaud.org.uk 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) Norman Laud Association Mrs Lesley Pamela Somerfield Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Emscote House DS0000016726.V328911.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 years Ms Somerfield completes the Registered Managers Award and NVQ 4 in care within 18 months of the date on this registration certificate. 21st March 2006 Date of last inspection Brief Description of the Service: Emscote House is registered to provide accommodation, care and support for up to eight people with learning disabilities, who may also have additional physical disabilities. This is a respite care service, aimed generally at serving the needs of younger adults. The property was purpose built: all respite accommodation is provided on the ground floor of the building, in single bedrooms. Rooms are designed to meet a varied range of support needs. The Home has well equipped standard and specialist (assisted) bathrooms, offering bathing and shower facilities. The kitchen links two roomy dining areas: both these rooms also double as areas for tabletop activities. There are also two well-furnished lounges that include televisions, video / DVD, stereo, and computer games console. The newly built conservatory also offers additional space for games, snooker table, parties and so on. There is an extensive private and enclosed garden to the rear of the property. At the front are shrub borders and parking spaces. The Home is situated at the end of a cul-de-sac in the residential area of Wylde Green. Local amenities include shops, library, medical centre, places of worship and a range of leisure and recreational facilities. The area is well served by public transport, including rail and bus routes. The current range of fees is reported to be £133.01 - £144.58 per overnight stay, and £66.51 – 72.29 for day care. (Fees charged to Local Authorities) Emscote House DS0000016726.V328911.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced. Information was collated from a number of sources including reports submitted by the Manager, previous inspection reports, and feedback from service users and their relatives. Direct observation and sampling of records (including personal files, care plans, staff files and safety records) were also used for the purposes of compiling this report. On the day of the inspection visit, the Inspector interviewed the Registered Manager and was able to meet with all eight service-users in residence. Unfortunately, the communication support needs and learning disability of some of the service users meant that it was not possible to seek their views directly. The Inspector also met with members of staff and the relative of one of the service users. In this report, people using the service are also referred to as “guests”, which is the preferred term. Thanks are due to the Manager, staff and people using the service for their cooperation and support throughout the inspection process. What the service does well: What has improved since the last inspection? The service continues to try to do all things well, and to listen to what people who use the service are telling them about it. People working in the service don’t want to stand still, they want to carry on making it better. Emscote House DS0000016726.V328911.R01.S.doc Version 5.2 Page 6 Further clear efforts have been made to recognise, understand, respect and value the differences among the people who use and work in the service. Work continues to improve the equipment and fittings in the home, to make each person’s stay as enjoyable and comfortable as possible 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. Emscote House DS0000016726.V328911.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 Emscote House DS0000016726.V328911.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, 3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are well supported to find out if this service is what they want. Their support needs are properly assessed before decisions are made about offering a service. EVIDENCE: Service users’ files were sample checked. All had detailed assessments in place as required. Evidence was also seen of an appropriate process designed to support potential service users make a decision about whether or not the service will meet their needs. This is backed by clear documentation that shows a schedule of introductory visits, a placement plan that is offered in alternative (“easy read / widget”) formats and evidence of a review to find out what the person thinks of the service offered. Emscote House DS0000016726.V328911.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): 6,7,8, & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ care plans include good information about their care needs and personal preferences, so that staff that support them know how they like things to be done. People are asked about what they want regularly so that the service can respond to their requests. Action is taken to keep people safe without preventing them doing things they like. EVIDENCE: Service users’ records (“guest profiles”) were examined. Care plans were detailed and included appropriate information about how support should be given and highlighted individual preferences (e.g. “prefers female carer”) Acknowledging that this is a respite service, and that rooms are used by many different people with different needs, it was good to note that there is a particular section in individual plans that looks at how each person would like the room to be arranged when they come to stay. Particular attention is also paid to night time routines. Risks are appropriately assessed and rooms Emscote House DS0000016726.V328911.R01.S.doc Version 5.2 Page 10 allocated according to individual need, taking account of relevant hazards. Some guests are known to move furniture or climb on it, so some rooms have fixed furniture to remove this potential hazard. Other guests are able to use “soft” rooms that include padded fixtures to prevent self-injury. Assessments are also used to find out what action needs to be taken to enable guests to participate in activities both at home and in the community, while maintaining personal safety. Plans are also reviewed regularly. Informal guest meetings are held each evening, this provides opportunities for people to explore choices and plan activities for the time that they are staying. A meeting is formally recorded once each week. It was noted that a “standing item” on the meeting agenda is to check if anyone wants space to discuss anything in private, and this represents further good practice. Previous inspection reports have raised issues about care plans including individuals’ agreed goals. It was noted that further positive action has been taken in this regard since the last inspection and that the current care plan format seeks to address this, and to ensure that goals set are both focussed and measurable. Emscote House DS0000016726.V328911.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People staying at Emscote House are able to take part in a wide range of activities that they value and enjoy, and to be a part of the local community. Staff respect their rights and encourage them to do what they can for themselves, so as to promote their independence. They recognise their diverse needs, personalities and cultures and help them maintain important relationships. Guests enjoy their food and are asked about and supported to get what they want. EVIDENCE: Guests staying at Emscote House usually continue to access their regular day activity programmes at local centres or places of education, if they have them. The service encourages and supports people to do this according to what they want. If guests do not have regular day placements, then a programme of activities can be structured to suit their individual needs. People are Emscote House DS0000016726.V328911.R01.S.doc Version 5.2 Page 12 encouraged to do as much for themselves as they are able, so as to promote or maintain their independence. As reported above, regular meetings are held with guests to plan activities. Records sampled showed that people were supported to access facilities in the community including shops, cinema, pubs, restaurants, local parks and day trips. If people want to stay in, then the home is well equipped to cater for a wide range of needs. Since the last inspection a new computer has been bought and staff are now busy seeking interesting and useful software to supplement the games and programmes they already have. They already have a range of mouse and joystick controls so that people who are more profoundly disabled are not excluded from enjoying using the equipment. In addition to this a new “soft play” area including a ball pool has been installed, to provide additional stimuli for guests with physical disabilities and sensory support needs. Existing equipment included a range of art and craft and other “table top” activities, pool table, TV and music and so on. Recording showed that people enjoyed relaxation sessions, hand massage, watching DVD; efforts were made to meet individuals’ cultural needs including watching Indian films and providing meals of other ethnic origin. Appropriate contact is maintained with people’s friends and families according to their wishes, while they stay at Emscote House. Indeed, for some people, a stay provides opportunities to meet up with friends and do activities together that can’t otherwise be managed. Staff clearly respect guests’ right to choose to engage in particular activities, or not. Sometimes it is necessary, when planning activities, to agree time limits on use of some of the equipment, to ensure that everyone who wants to gets an opportunity to use it. One service user was unhappy about coming to Emscote, so staff supported him to deal with this with his parents, respecting his right to choose not to do something that he was not comfortable with. Of particular note are the continued efforts the service makes to recognise the need for awareness of equality and diversity issues. Information around the home is supported in a variety of ways including pictorial aides, replication of Makaton symbols and other easy read / alternative formats, objects of reference, as well as some material in languages other than English. There are pictures and posters displayed highlighting disability, diversity and equality issues. The home keeps an information pack on disability issues and another on cultural awareness. There are photographs of members of the care team on display, so that guests know who is on duty. There is a realistic understanding of what these efforts might achieve, and recognition of their limitations. Conversations with the Manager showed a positive attitude towards working on this and a “mindset” that says any perceived lack of success will not be for want of trying. Emscote House DS0000016726.V328911.R01.S.doc Version 5.2 Page 13 Guests were observed taking their evening meal. Staff supported them appropriately where required in a relaxed and unhurried way. Sampled care plans included detailed dietary guidelines, as well as professional advice and input from parents. Food stocks were examined: these were plentiful and included fresh fruit and vegetables. Records of meals taken showed balance and variety. Service users who were able said that they enjoyed the food and were asked about and could have what they wanted. Emscote House DS0000016726.V328911.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’ personal and healthcare needs are well met while staying at Emscote House. Care is taken to assess and plan support according to what people need and want. Guests are protected by good practice in handling storing and administering their medication. EVIDENCE: As reported above, care is taken to gather appropriate information about how people like to be supported, so that care plans are properly informed. It was noted that one person’s plan had detailed guidance about his manual handling requirements and use of hoist slings. Basic personal care is given to a very good standard: guests’ clothing and grooming provided evidence of this. Staff were directly observed supporting guests. They engaged appropriately and took their time, speaking to people directly and encouraging them to do things for themselves if they could. Support was given with warmth and friendliness, and it was clear that both guests and staff were comfortable with each other. Individuals’ healthcare needs are assessed prior to admission, and identified support is included in care plans as required. Because the service is for respite Emscote House DS0000016726.V328911.R01.S.doc Version 5.2 Page 15 care, staff are not responsible for health action planning, but support guests’ healthcare needs as agreed with their families / main carers. It is standard practice in the home to check in all medication as soon as a guest arrives, to ensure that everything is as it should be and that all medicines to be administered are present and correctly labelled. The Medication Administration Record (MAR) was examined and had been completed appropriately. Written protocols were in place for all PRN (“as required”) medication and there was additional information on the drugs prescribed, including uses and possible known side effects. Individual records included the guest’s photograph. The medication store was examined. This was clean and tidy and included a facility for storing controlled drugs if required. There were none held on the day of the visit. Emscote House DS0000016726.V328911.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 can be confident that their concerns are taken seriously, listened to and acted upon. They are protected from abuse, neglect and self-harm. EVIDENCE: No complaints have been received in respect of this service. There is a very open “complaints culture” at Emscote House. As indicated in previous inspection reports, there is a “post-box” in place inside the front door, with a supply of pens and forms for guests or visitors to register any comments they might wish to make about the service. The Manager checks this regularly. There is an appropriate formal complaints policy and procedure in place, and this is also prominently posted in the hallway in Punjabi and Urdu and in a Makaton format. Good use is also made of the “grumbles book”, which is a record of issues of concern raised by people who do not wish to complain formally. This book was also examined and contained details of the concern, the response and the outcome. The service policy and procedure on adult protection incorporates local multiagency guidelines. Members of the staff team have received appropriate training. Many of the people using this service are reliant on their vigilance to notice changes in behaviour or demeanour as indicators that something is amiss. Staff interviewed showed that they understood the different types of abuse and knew what action to take in the event of any concerns that an incident of abuse might have taken place. Emscote House DS0000016726.V328911.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, 25, 26, 27, 28, 29 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Emscote House provides its guests with a welcoming place in which to enjoy their stay. The building is very well equipped to cater for people with a wide range of support needs. It is homely clean and comfortable. EVIDENCE: A tour of the building was completed. Emscote House is a purpose built facility, providing guests with a comfortable and homely environment. As reported previously, the building is decorated, fitted and furnished to a very high standard. It can cater for people with a wide range of support needs. Bedrooms are comfortable and a lot of thought has gone into individual design, adaptability and flexibility according to what guests require. Bathing and washing facilities are available for people who can do this independently through to those who require full assistance. The Manager advised that a new “Parker” bath is on order and that ceiling tracking hoists are also to be fitted – final decisions are to be made about exact locations shortly. Toilet facilities are fully accessible also, including grab rails. Emscote House DS0000016726.V328911.R01.S.doc Version 5.2 Page 18 Shared spaces include two dining areas, which are also used for other activities, two lounges and a conservatory. All of these spaces are “multifunctional” and used flexibly according to what guests want to do. The conservatory, for instance, houses the new computer and pool table and football games. These can all be cleared away so that it can be a “quiet space”, and it also gets used for parties. The dining room also has space for storage of art and craft materials and other tabletop activities. On the wall is an “objects of reference” board to facilitate communication and offering choices. The communal areas of the home look out onto a large, private and enclosed garden at the rear of the property. This is a well-maintained and attractive space, with areas to sit out and enjoy being outside, when the weather permits. The building was clean and tidy and a good standard of hygiene maintained throughout. Emscote House DS0000016726.V328911.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. Service users enjoy the benefit of being looked after by a well-qualified, trained and motivated staff team that is also well supported. They are protected by the home’s policy and practice with regard to selection and recruitment of staff. EVIDENCE: Previous inspection reports have referred to the service’s high commitment to training, and this remains the case. Staff are actively encouraged to work towards gaining appropriate qualifications, and the majority of the care team are qualified at NVQ level 2 and above. Training is planned and delivered on a regular basis, and development kept under review throughout the year. The Manager is currently looking into staff doing Learning Disability Awards Framework training to underpin knowledge gained studying for NVQ qualifications. Staff files were sample checked and provided evidence of an appropriately robust recruitment process. Records included completed application forms, two written references, Criminal Records Bureau /Protection Of Vulnerable Adults Emscote House DS0000016726.V328911.R01.S.doc Version 5.2 Page 20 list checks, evidence of induction and training and development. Formal supervision is scheduled on a monthly basis, and staff receive an annual appraisal. Staff group meetings also take place regularly and frequently. The Manager advised that, as part of general service development, a new format is being devised for staff induction. There is a good team spirit amongst the staff group, and observations of interactions suggest they are well motivated and support each other well. Observations of interactions with service users show that they are sensitive to individuals’ needs and committed to making them feel “at home” while they are in their care. Emscote House DS0000016726.V328911.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, 38, 39, & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Guests enjoy using a service that is very well run for their benefit. The service is highly valued by the people who use it and their families. People’s health safety and welfare are generally well protected. EVIDENCE: The Manager advised that she has now gained qualification at NVQ level 4, and is awaiting certification. She holds the Registered Managers Award already. She is supported by well-qualified deputy managers, and the home’s management team works well together, demonstrating a very positive attitude to developing the service for the benefit of the people who use it. The style of management is open and inclusive. Emscote House DS0000016726.V328911.R01.S.doc Version 5.2 Page 22 The Manager advised that a formal system for quality assurance and monitoring has now been introduced (PQASSO) and the report is awaited. The organisation already holds the Investors in People Award. The service actively seeks the views of service users and their families. One carer wrote “Thank you for the wonderful care, love and attention that (N) received whilst in your care”. Another said, “We enjoyed a week’s break knowing (N) was well cared for”. One service user’s mother sent a letter saying, “ Life without Emscote would not be something I would like to consider, keep up the good work. (N) really has a better life….every visit is like a holiday”. One of the regular service users had his testimony published in a newsletter. He said, “ You help me by being independent. I like coming to Emscote anyway. I like the activities, going out to the shops, cinema…..it helps me have a break from my family, and gives my parents a break from me……if I couldn’t come I’d be very annoyed”. Another service user commented at a review meeting “ I like the activities at Emscote and going out for lunch. I wish I could come more often.” The Inspector was able to meet with the mother of one of the service users who was staying at the time of the inspection visit. She reinforced the views expressed above and her son said that he enjoyed staying at Emscote and looked forward to coming there. Safety records were sample checked. The fire alarm and fire-fighting equipment have been serviced. The alarm and emergency lighting systems have been checked regularly as required and a full record kept. Fire evacuation drills have been carried out. The Landlords Gas Safety Certificate and electrical hard wiring certificate are both in date, and portable appliance testing of electrical equipment has been carried out. The assisted bath, shower trolley and hoists have all been serviced. The home’s vehicle has a current MOT certificate, the tail lift has been serviced, and there is a completed record of monthly checks. There was a complete record of cooked food temperature tests. Fridge and freezer (including the medication fridge) temperatures had been checked regularly, but it was noted that there were some gaps in recording. The Manager advised that all safety checks are audited monthly, so that any issues are picked up and followed through. Emscote House DS0000016726.V328911.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 3 4 3 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 4 25 4 26 4 27 4 28 4 29 4 30 4 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 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Emscote House DS0000016726.V328911.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA42 Regulation 13 (4c) Requirement The registered Manager must ensure that fridge and freezer temperatures are checked daily and a complete written record maintained. Timescale for action 01/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA39 Good Practice Recommendations Publish annual report of quality assurance and monitoring activity, and make it available to all interested parties. Emscote House DS0000016726.V328911.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Emscote House DS0000016726.V328911.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. 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