Inspection on 25/10/05 for Endsleigh House

This inspection was carried out on 25th October 2005.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Endsleigh House 21/10/08

Endsleigh House 15/05/08

Endsleigh House 10/08/06

Endsleigh House 08/08/05

Endsleigh House 25/01/05

Endsleigh House 19/01/05

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Endsleigh House 46 Endsleigh Gardens Ilford Essex IG1 3EH Lead Inspector Stanley Phipps Unannounced Inspection 25 October 2005 13:40 Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 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 Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 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. Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Endsleigh House Address 46 Endsleigh Gardens Ilford Essex IG1 3EH 0208 554 1167 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 Yuhya Roojee Mr Yuhya Roojee Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2005 Brief Description of the Service: Endsleigh House is a care home providing personal care and accommodation for five people ages 18-65 with a history of mental illness, who need support in order to live in the community. It is privately owned and registered by MR Yuhya Roojee. The home is located on a residential street in Ilford and is close to all community facilities. These include a wide range of shops, pubs, the post office, entertainment centres, parks and library facilities. The home consists of five single bedrooms, two of which are located on the ground floor. Access to the first floor is via two sets of stairs. There are two reception rooms on the ground floor, one of which is used for dining and the other for relaxation and viewing television. A small conservatory has been constructed for service users who smoke. A rear garden that is domestic in scale is available for the enjoyment of all service users and is easily accessible from the kitchen and smoking area. A group of staff is on hand to provide twenty-four care and support to service users. Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place in just over three hours and was timed to coincide with meeting service users, assessing the progress made from the last inspection, as well as the evening meal. It was the third visit since the service was registered. The inspection found that there have been significant improvements and service users shared the same view. There were, however, a small number of improvements that are needed to ensure full compliance with the national minimum standards for younger adults. It must be stated that the registered manager continued to work positively with the Commission in both improving the quality of service provision and complying with the minimum requirements. An assessment of menus, service user plans, policies and procedures and the environment was undertaken. Discussions were held with four service users, the manager, along with an interview with one of the care staff. The environment assessment included the communal areas and the bedroom of a service user. This report covers all the national minimum standards that were not assessed at the first visit along with those standards that were not satisfied following the previous visit. What the service does well: The registered manager and staff continue to maintain a safe environment for service users - one that is relaxed and calm. This enables service users to interact in manner that is not pressured, as they go about their daily routines and objectives. Evidence could be drawn from the fact that despite the complexity of need amongst the service user group, it was clear that they enjoyed sound periods of stability. There was also evidence that the pre-admission and continuing assessments of service users were quite detailed, which gave a good basis for determining the specific needs of individuals. Following this, service user plans were also detailed and specific to service users’ needs and it was clear that they were involved in preparing them. One of the strengths evidently clear during the visit, was that the specific health care needs of individuals were well catered for. This ensured that service users remained healthy, which positively impacted upon their level of engagement with the home and wider community. Service users were very involved in most aspects of the home and there was evidence to confirm that the management and staff work well in helping to improve the community participation and presence of the service user group. Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: More could be done to support staff by conducting more frequent supervision. It was accepted that Endsleigh is a relatively small home - five beds, so that the manager is in close daily contact with both the staff and service users. However, given the varying needs of the service user group and the expectations placed on staff to provide a quality service, there needs to be dedicated and frequent formal supervision for all care staff in the home. The registered manager could also work more towards ensuring that the environment, including the upstairs bathroom is decorated to give a more homely feel to it. A requirement was previously made regarding this and there was little evidence to demonstrate that improvements were made in this area, although there was evidence that some things have been purchased e.g. houseplants. They would need to be positioned to ensure that it adds to the a bit of ambience to the home. From assessing the records held by the home for the protection of service users, most were in place as required by regulation, however records kept on staff must include all areas listed in Schedule 2 of the Care Homes Regulations, if they are to provide a safeguard for service users. Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 Page 7 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. Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 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 Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (2,3) Prospective service users are assured that their needs would be thoroughly assessed prior to coming into Endsleigh. This allows opportunities for determining the suitability of the service in meeting those needs. EVIDENCE: From the records viewed and speaking to service users, it was observed that that detailed assessments are carried out on service users prior to their admission to the home. At the time of the visit there was evidence that over three initial assessments were carried out by the manager himself who is a registered mental health nurse. They were conducted on service users who were interested in using the services at Endsleigh. As part of the admission process of the home, one was earmarked to visit the week following the inspection, as part of his assessment of the services. This allowed him an opportunity to get a bird’s eye view of the on how the home is run, which included meeting service users and staff. One service user spoken to confirmed that prior to coming into the home – he had the opportunity to visit and he was happy that he did, as he thought it was: ‘better to see it yourself, if you can’. As such it was conclusive that the home has a detailed admission process which ensures that service users needs could be met as well as ensuring that each service user has confidence in Endsleigh House meeting their needs. Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (6,7,8,9,10) The needs of service users are well documented in their individual service user plans, which are reviewed as changes occur. They are involved in negotiating their daily routines and objectives and are empowered through the risk management strategies of the home. As a matter of course, service users benefit from being able to contribute to all aspects of life in the home and are assured that information is held on them is handled sensitively and in their best interests. EVIDENCE: Service users spoken to confirmed their involvement and knowledge in planning their personal, health and social objectives. This was done in conjunction with their individual key-worker – all of whom had an assigned person. These objectives were well documented in their service user plan, which they signed up to. Detailed examples of such objectives included the level of support required with personal hygiene, budgeting and/or skills involved in keeping their bedroom clean and safe. A key tool that is used alongside the plan is the risk assessments, which were in place for each service user to ensure that service users are allowed to maximise their full potential within a risk management framework. This empowers service users to get up and do more individually e.g. go out to college in pursuit of enhancing their education or to attend work schemes to give them a bit more Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 Page 11 independence. The important issue here is that both the staff and service users put a value in what they do. There was evidence of service users being consulted as a routine part of living in the home. From assessing the minutes of service users meetings, it was found that apart from being regular, it is one of the main forums for eliciting the views of service users e.g. where they would like to holiday, how they spend their leisure time internally and out in the community, what’s acceptable behaviour in the home, protocols for when they go out and the types of meals they enjoy. It was clear that contributions were obtained from all service users though some were more vocal than others. Service users also make contributions informally where they approach the manager directly and this is encouraged and achievable due the size of the home and the accessibility of the manager. One service user, during the course of the inspection approached the manager about wanting to discuss an idea for a social activity and this was facilitated. From the interview held with the senior staff on duty, it was clear that there was a sound awareness of how information held on service users is safely handled for their protection. This awareness was in line with the home’s policy on confidentiality and the sharing of information with other agencies. The files of service users are securely maintained in a locked cabinet in the promotion of confidentiality, particularly as service users are quite often in and out of the office for various reasons at various times. Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (11,12,13,14,16,17) Service users at Endsleigh House are encouraged to participate in appropriate activities and have opportunities to develop and maintain social and personal networks of their choosing. This gives them something invaluable to look forward to and helps to reinforce the rights of service users. Meals have improved and are now satisfactory in content, more varied and reflective of service users’ cultural needs. EVIDENCE: Each service user has an individual programme of activity that reflects their choice and/or interests. In assessing these programmes it was clear that individuals were at different stages of their life as levels of motivation varied from individual to individual. However it must be said that the staffing input and their strategies for motivating service users were quite good and there are bits of successes in enabling individuals to achieve their goals. They (staff) use service users’ strengths as a way of positively engaging them in achieving their goals. A good example could be drawn from the fact that one service user loves football and supports a London Premiership Team. Although difficult to engage, he spends time playing paper football and occasionally going down to the local park to keep his interest alive. This is positively encouraged by staff Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 Page 13 as there is no attempt to impose their expectations on the achievements of service users. Another service user wants to pursue computer studies and he is supported by his key-worker to engage with a college to pursue his goal. This service user has also started swimming and informed that he enjoys this. Another positive example could be drawn from the fact that a service user attends a work scheme and this is something that he really wanted to do. From the evidence gathered staff have been supportive in enabling him to keep up his attendance and this is now a major feature of his life. Leisure pursuits in the home depended on interests and from the evidence gathered they involved things like trips to the local parks, pubs, cinema, leisure and on Fridays – the Outlook Express. All service users expressed satisfaction with the leisure activities in the home, which also included a oneday trip to the coast prior to the visit. Plans were afoot to arranging a holiday away from the home and service users were involved in the determination of this. Most of the service users have friends, either from the institutions from which they were previously placed or from new associations e.g. one has a friend from college and this is encouraged by staff. The same is true where service users have relatives and these networks are maintained either through visits to or out of the home as well as through telephone communications. Relatives and friends are also invited to the home for social events and service users confirmed that they are pleased with the staff support in this area. As an improvement from the last inspection service users had greater access to advocacy services that were specific to their needs and this was advertised on their notice board in the dining area of the home. It was noted that up to three of the four service users generally felt that they could handle their own affairs and this was acknowledged by the management and staff at the home. Another improvement since the last inspection was with regards to meals in the home. There was evidence that they were now recorded and that a clear process was in place to ensure that their wishes and cultural preferences were taken into account. The four service users currently in the home expressed their satisfaction with the meals provided at Endsleigh House. From the staffing records up to two staff had received food hygiene training and this was also an improvement when compared to the last visit. Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (18,19,21) Sound arrangements are in place for monitoring and supporting service users with their health and personal care. Key work sessions and effective links with multi-professionals ensures that their psychological and emotional needs are also met. More guidance is required in relation to managing service users, should they die in the home. EVIDENCE: During discussions with service users, they expressed their satisfaction with the quality of staff support in the home. It was acknowledged that the needs of service users were varied and as such the level of input was higher in some than others in key areas such as personal care and dealing with more complex issues such as going to college or to a day centre. Service users’ records bore evidence of interventions made with individual service users and it was positive that their individual preferences were taken into account. Each service user was registered with a GP and there was evidence that they all seen by the dentist and opticians between September and October 2005. At the time of the visit the manager was in the process of reviewing the health care record to ensure that it was more accessible at a glance. There was evidence that staff were involved in supporting service users who became anxious and/or agitated and this was done usually on a one to one or key-work sessions. A key part of this process involved being aware of the triggers, which Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 Page 15 may indicate when a service user may be unwell. Staff are also proactive in working with the relevant psychiatrist and/or community psychiatric nurse in acquiring specialist support for the benefit of service users. It was clear that service users maintain good periods of stability at Endsleigh and hence a good quality of life in the community. Although the current service users are young adults, it is important that guidance is in place that takes into consideration their wishes should they become unwell or die while in the home. This would enable staff to give them the best possible support should the situation arise. It was noted that there have been no deaths in the home since its inception, but there was nothing to preclude this from happening in the future. In essence it would be positive for all concerned if systems are in place to deal with this eventuality. Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (22,23) Service users and their relatives can feel reassured that concerns, when raised would be taken seriously through a timely and thorough investigation, which is in line with Endsleigh House’s complaints procedure. Improvements have made to ensure that service users are safe and protected from abuse. EVIDENCE: An active and comprehensive complaint’s procedure is in place and this is well advertised in the home. As a matter of course service users and/or relatives are encouraged to talk about issues they may have a concern with. This allows the management and staff an opportunity to make early interventions to reduce the risk of problems arising. Service users in the main have the added advantage of raising issues informally and in service user meetings. There were no complaints on record, however various issues were discussed at their service user meetings. Service users spoken to were aware of the procedure and importantly who to contact if they were unhappy with how a complaint is handled by the home. Improvements were made with regard to protecting service users from abuse in that four staff members were booked on to have adult protection training. Staff interviewed showed a sound awareness of what they need to do if they suspected abuse or if an allegation of abuse was made to them. There were no adult protection issues in the home. Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (25,26,27,28,29) Service users enjoy a clean and comfortable environment at Endsleigh House and this is viewed positively and appreciated by them all. Personal spaces are now more reflective of service users likes. However, further improvements Are required to the main bathroom on the first floor and the corridors to give the home a more homely feel. EVIDENCE: The home was clean and maintained to a good standard and this is a joint effort between the staff and service users living there. Improvements were noted with regard to personalising service user’s bedrooms, replacing/replacing broken tiles in the kitchen, replacement of damaged patio tiles and the rear fence has been redone to a really high standard. Improvements were still required to make the home more homely e.g. hanging some pictures on the wall in the passageway from the front door and up the stairwell. The main bathroom, though suitable for meeting the cleansing needs of service users, is still very bare and ordinary without any form of mirrors for service users to see their faces for example when shaving. There are adequate shared spaces for the number of service users in the home as there is the main lounge, a separate dining area, a small smoking room and a quite room on the first floor with a telephone. In concluding, the building is suitable for its purpose and service users currently do not require specialist Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 Page 18 equipment to maximise their independence as they very able to use their environment to maximise effect. All toilets and bathrooms are lockable and provide service users with security and safety, which they enjoy. Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (32,33,36) Service users at Endsleigh House benefit from having a dedicated manager and staff team who work well together to enhance the quality of services they receive. It remains important however, that all staff receive more frequently, formal supervision in supporting them to carry out there roles with greater authority. EVIDENCE: From observing the staff at work it was clear that they carried out their interventions and support work with service users with a fair degree of confidence. They knew and understood the needs of the service user group and worked well as a team in meeting them. This is reinforced and enhanced by the input and expertise of the registered manager who is accessible, proving them with relevant guidance. Staff interviewed confirmed that they felt supported by the manager. Staffing records viewed bore evidence that staff were in receipt of both training and formal supervision. Training included areas such as first aid, food hygiene and NVQ level 2 training and this enabled staff to practise safer in promoting good quality care. Although staff were in receipt of formal supervision, it was below the frequency required by the national minimum standard and this was pointed to the registered manager for improvement. It was noted that due to the size of the home that the manager works closely with his staff and in many respects is always accessible to both the staff and service users. However, both groups would benefit from the staff having more frequent and dedicated time looking at care practice, the philosophy of care and professional development. Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 Page 20 The staff composition is determined by needs of the service users and in the main, there is a minimum of two staff is on during the day shift, with one person on at night. On call support is available and the manager takes responsibility for this. It was confirmed that, he could reach the home in the event of a crisis within quick time, so that staff is not put at risk. Changes in service users’ needs are discussed on each shift at handover and the night cover increases if this is required. It was clear that this system was effective in that service users were maintaining sustained periods of stability and generally making good individual progress – living in the home. Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (38,40,41) Sound management systems in place to enable service users to receive a high standard of care at Endsleigh House. Having an experienced manager who is accessible to service users, staff team that is willing and committed to working with the service user group enhances this. More needs to be done however, in ensure that records for the protection of service users are in line with regulation. EVIDENCE: The daily management of the home is sound and both service users and staff confirmed this. They felt that the manager was easily available to them for support and guidance and it was observed that he (the manager) has a very good rapport with both groups. It was also very clear that he leads from the front and knew in detail of the needs of each individual service user, as well as prospective service users. Sound evidence was in place to confirm that regular staff meetings are held i.e. at least two-monthly and they are very detailed covering all aspects of the service. This is positive as staff are not only wellinformed, but also make significant contributions to the service developments. Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 Page 22 There is a sound framework of policies and procedures available to all staff, giving them the relevant guidance to carry out their duties safely and to a high standard. There was one deficiency in a ‘ death and dying’ policy which has already been covered earlier in this report. Service users and their relatives could feel assured that staff have most of the guidance to enable them to meet their needs. This is enhanced by the fact that the home also maintains records safely and in the service user’s best interests. Some examples include, records on complaints, accidents, food, details held on service users to include service user plans/risk assessments, health and safety and records on staffing. It was noted however, that the latter required some improvement if they are to offer service users maximum protection, as they must be in line with Schedule 2 of the Care Homes Regulations 2001. Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 X x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X 3 3 2 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 3 X 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Endsleigh House Score 3 3 X 2 Standard No 37 38 39 40 41 42 43 Score X 3 X 3 2 X x DS0000041823.V261597.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? YES 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 2 Standard YA21 YA27 Regulation 12 23 Requirement The registered manager is required to develop a policy on ‘death and dying’. The registered manager is required to upgrade the main bathroom and provide a more homely environment through the use of pictures on walls and plants in areas of the home in discussion with service users. (This is part of a previously made requirement). The registered manager is required to provide formal supervision at least on a twomonthly basis for all staff. The registered manager is required maintain records for all staff in line with Schedule 2 of the Care Homes Regulations 2001. Timescale for action 21/01/06 25/01/06 3 YA36 18(2) 31/01/06 4 YA41 19 21/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 Page 25 No. Refer to Standard Good Practice Recommendations Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 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 Endsleigh House DS0000041823.V261597.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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