Inspection on 24/06/08 for Essex Care Consortium Colchester

This inspection was carried out on 24th June 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Essex Care Consortium Colchester 26/06/07

Essex Care Consortium Colchester 26/01/06

Essex Care Consortium Colchester 01/03/05

Essex Care Consortium Colchester 14/09/04

Essex Care Consortium Colchester 15/03/04

Essex Care Consortium Colchester 28/08/03

Essex Care Consortium Colchester 13/08/02

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

CARE HOME ADULTS 18-65 Essex Care Consortium Colchester Maldon Road Birch Colchester Essex CO2 0NU Lead Inspector Neal Cranmer Unannounced Inspection 24th June 2008 09:30 Essex Care Consortium Colchester DS0000017838.V367052.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 Essex Care Consortium Colchester DS0000017838.V367052.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. Essex Care Consortium Colchester DS0000017838.V367052.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Essex Care Consortium Colchester Address Maldon Road Birch Colchester Essex CO2 0NU 01206 330308 01206 331811 ecarecinfo@btconnect.com www.e-care-c.co.uk Ms Gillian Oliver Ms Bethan Oliver Ms Katrina Lingley Care Home 19 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) Category(ies) of Learning disability (19) registration, with number of places Essex Care Consortium Colchester DS0000017838.V367052.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 19 persons) Children of either sex, aged between 16 and 18 years of age, who require care by reason of a learning disability (not to exceed 18 people) 26th June 2007 Date of last inspection Brief Description of the Service: The service consists of two main dwellings, of bungalow design and a single self-contained first floor studio apartment. Other buildings on site include office accommodation and a day services centre. The site is within a rural location, set in several acres of grounds. The facilities include substantial outdoor activities, including a swimming pool. The service has its own transport via multi purpose vehicles; in view of the location this is an important provision. Public transport, however, does pass the premises and provides access to Colchester town centre to the east and Maldon to the west. The service offers a wide variety of support to adults who have a learning disability. Fees for residing in the home are between £690.92 and £2.236.10 per week, and included day care, and any additional 1.1 hours. Additional charges are made for hairdressing and chiropody. This information was provided at the time of the site visit. Essex Care Consortium Colchester DS0000017838.V367052.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars. This means the people who use this service experience good quality outcomes. This report is the outcome of a key unannounced inspection, which focussed on the key standards relating to care homes for young adults. The site visit was undertaken on a weekday and took place over approximately 8.00 hours. The report has been written using accumulated evidence gathered prior to and during the site visit, including the homes (AQAA) Annual Quality Self Assessment. The inspection process included examination of a range of documents including staff training and recruitment records, four service users files, a selection of policies and procedures and health and safety records. The inspector also toured the premises and grounds and spoke with service users and staff. The registered manager of the home’s sister service was present throughout the inspection and contributed fully to the inspection process. What the service does well: Staff are very open and focussed upon achieving the best outcome for service users. Service users have access to a good range of daytime activities both within the service and in the wider community. The premises were generally well furnished, homely clean and safe, and there is an on-going plan in place for further refurbishment. Staff working in the home are well trained, and are regularly provided with refresher training. They are also well supported by a good management structure, and receive regular formal supervision. Staff working in the home are well supported by a good management structure, and receive regular formal supervision. The organisation has consistently achieved externally validated quality assurance and an Investor In People Award; this award focuses on staffing, supervision and training. What has improved since the last inspection? Essex Care Consortium Colchester DS0000017838.V367052.R01.S.doc Version 5.2 Page 6 The home has undergone some refurbishment, and bathrooms, toilets and the dining room area are now comfortable and are adequate to meet service users needs. The service now has in place an effective quality assurance system, based upon the views of service users, and which is designed to measure the success of the home in achieving the aims and objectives set out in the home’s Statement of Purpose and Service Users Guide. 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. Essex Care Consortium Colchester DS0000017838.V367052.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 Essex Care Consortium Colchester DS0000017838.V367052.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): 1 and 2. Quality in this outcome area is good. People who may use the service and their representatives have the information needed to choose a home that will meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has in place a comprehensive Statement of Purpose and Service Users guide, both of which were seen to provide all of the necessary information required to enable people to make a choice about the home’s ability to meet their needs. The Statement of Purpose was last reviewed in April 2008 and included clear aims and objectives, details about the management team including their qualifications, the arrangements for admission, arrangements for the process of care planning, the organisational structure and a copy of the home’s complaints procedure. Both documents were well presented visually and included symbols to help people understand, including pictorial information of people going about their every day lives. Essex Care Consortium Colchester DS0000017838.V367052.R01.S.doc Version 5.2 Page 9 There has been one new admission made to the home since the last inspection visit, sampling of records in relation to this admission showed that a transition plan had been put into place, which showed evidence of day visits and overnight stays to the home, to meet the other people living there. An interim review took place two months after admission, which was attended by the service user, their care manager, the registered manager and their assistant. The initial assessment form that the home uses during the assessment process enables the assessor to gather information on a range of information relating to the service user and their care needs including: family contacts, the name of any appointee if any, professional input being provided, any known disability and diagnosis, communication, self help skills and sleep patterns. The assessment also contained information about the service users specific likes and dislikes. The assessment used by the home was seen to be supplemented by a Social Services assessment known as a COM 5 (Community Care Assessment). Essex Care Consortium Colchester DS0000017838.V367052.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): 6, 7 and 9. Quality in this outcome area is good. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four service users care plans were sampled as part of the case tracking process, all of which were detailed and comprehensive, containing specific information about how people liked to be supported, for example how I like to be supported to meet my hygiene needs. The care planning structure is currently under review, and they are in some cases running with two systems of care planning. However both were reviewed and were found to be well presented and provided evidence of a person centred approach, including information about important issues including: Essex Care Consortium Colchester DS0000017838.V367052.R01.S.doc Version 5.2 Page 11 Things I want you to know about me, days I would like to remember, how I like things to be done, and who I want to be involved in my care. The new care planning process is being developed to take account of the new Mental Capacity Act, and new care plans are in the process of being developed and included four key areas; A needs assessment, mental capacity assessment, support plan, my plan and evaluation. Staff are currently undergoing training, and as soon as this is completed they commence the development of the new care plans in consultation with the service users. This consultation is a key part of the new plans and staff are required to provide evidence in the plans of how service users have been involved in the development of their care plan. Both systems sampled were well presented and provided staff with clear guidelines, in addition there was data relating to risk assessment from which care decisions are made. Both systems viewed indicated that the approach was with the consent and co-operation of service users. All of the polices, procedures and information provided in the home was seen to be provided in formats that were useable and accessible to the service users, and there was evidence within the Statement of Purpose, Service Users Guide that service users had been actively involved in their development. The service does hold personal monies in safe custody on behalf of service users. The service has in place an audit system for tracking expenditure and the cash records were sampled for two service users. Both of the balances seen were accurate and accounted for and the systems in place indicated that service users are protected by service’s financial arrangements. The service has a suitable risk framework and the tools used are appropriate to safeguard service users whilst encouraging maximum independence. A number of the service users who are more able are actively involved in the gardening project, and oversee the maintenance of the garden areas, using mowing machines and other gardening apparatus, risk assessments were in place relating to these activities. Essex Care Consortium Colchester DS0000017838.V367052.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. People who use the service are able to make choices about their life style, and are supported to develop their life skills, social, educational, cultural and recreational activities meet individual’s expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Situated in the grounds of the home is another service known as the ‘Access Centre.’ This centre is individually run, managed and staffed and provides day services to people coming in from the community as well as those living on site. Many of the service users attend this centre on a daily basis and from there they access a range of community based activities including the cinema, bowling, swimming, the local library, and local colleges. In house activities provided included art and craft classes, cookery, lifestyles classes and music classes. The inspector visited a number of these classes and was able to see Essex Care Consortium Colchester DS0000017838.V367052.R01.S.doc Version 5.2 Page 13 service users being actively involved, a number of service users were keen to show their work to the inspector. The home continues to have access to it’s own heated swimming pool area, where during summer months many outdoor activities take place including birthdays and bar-be-que’s. Photographic evidence was seen of some of these events. Other service users were observed out in the garden and were seen attending to the home’s allotment where they grow flowers and vegetables, which the member of staff pointed out they sell or sometimes take home to eat. At the time of the inspection visit the service users were playing host to a slow worm and its baby that had taken up residence in their compost heap, both mum and baby reported to be doing well, and were a topic of much discussion. Discussion with some of these service users indicated that they enjoyed working in the garden and attending to the allotment. One service user has a voluntary job in Colchester, but was not available to discuss this with at the time of the inspection, due to being out at work. The home has an open door policy on the receiving of visitors, and service users are supported by their key workers to maintain links with their families and friends. Care plans seen reflected details of those people important to the service users, and included details of important dates such as birthdays. Records were seen to be kept in service users care plans of visits from family members. On the day of the visit relatives were seen visiting the home to bring in small items to be used in the home’s forthcoming summer fair. The house rules within each dwelling were flexible as possible, although it was noted that some service users required some structure and increased level of supervision based upon their individual needs. The daily routines and any restrictions on these were in line with supporting people to be as independent and as empowered as possible. Mealtimes were not observed on this occasion, although the menus seen were varied and nutritious, and provided a balanced and varied diet. Records indicated that meals were provided flexibly to accommodate service users daytime activities, and it was noted from records that the main cooked meal is usually provided at nighttime with this in mind. Essex Care Consortium Colchester DS0000017838.V367052.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 and 20.Quality in this outcome area is good. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA states that care plans are drawn up with individuals to include choice in how they wish to be supported. The plans contain information to support staff in how to meet their needs appropriately and this was confirmed in records examined. The personal care needs give precise details about how much support is required and the way that it should be provided so that staff receive guidance to ensure care is consistent. Service users abilities are well detailed so that staff know how much or how little support is needed to help them to maintain their independence. Based upon the sample of care plans sampled all service users are registered with the local GP practice. Healthcare matters, including optician and dentist Essex Care Consortium Colchester DS0000017838.V367052.R01.S.doc Version 5.2 Page 15 are planned in advance for each person. Appointments are taken within the community in keeping with the ethos of the service unless it is necessary for a home visit in the same manner as anyone living within the community. From the sample files examined it was noted that the healthcare part of the plan was well designed and enables easy tracking of healthcare appointments and follow up actions where necessary. The service carries out a monthly service user health check, which is designed to monitor any changes in health. The arrangements for service users prescribed medicine were reviewed. All service users have their prescribed medicines held in safe custody by the service and care workers administer medicines. The service operates a monitored dosage system (MDS). Medicines are securely held when not in use within small steel lockable cabinets, held in each service user’s room. Mechanisms were in place for monitoring and auditing medication and are carried out weekly by the registered manager. Discussion with staff in one house indicated that medication is always administered by two staff, one administering and one witnessing, sampling of records showed that there were no gaps or omissions. Each service user’s medication record includes a photograph of the individual as well as a record sheet of prescribed medication along with any possible side effects. All staff working in the home administer medication, but only upon completion of external training provided by local pharmacists, in addition to this training they undertake three observations of practice carried out in-house. Essex Care Consortium Colchester DS0000017838.V367052.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 and 23. Quality in this outcome area is good. People who use the service are able to express their concerns, and have access to a robust, effective complaints and adult protection procedures, which ensures their concerns are addressed, and that they are protected from harm or abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service maintains a complaint procedure, which is available in an easy read and symbol format. In addition to this the home provides complaints leaflets specifically for: staff, relatives, advocates, and external professionals and contractors. The Manager advised that no complaints have been investigated during the period since the previous inspection although written compliments received by the service had been received. The format of the complaint procedure and its use remains the same as at the previous inspection and therefore continues to comply with National Minimum Standards, and ensure that service users are adequately protected. The service has in place a safeguarding adults policy and procedure, and in a similar way to complaints, the format is made easier for people by easy read and symbol formats. There have not been any adult protection referrals made in respect of the home since the last inspection. Essex Care Consortium Colchester DS0000017838.V367052.R01.S.doc Version 5.2 Page 17 Discussion with the registered manager indicated that all staff have been provided with adult protection training, and all staff are provided with a copy of the policy in the staff handbook that they are provided with at the commencement of their employment in the home. Discussion with staff indicated that they were aware of what to do in the event of an allegation being made. Essex Care Consortium Colchester DS0000017838.V367052.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. The physical design and layout of the home enables people to live in a safe, well-maintained and comfortable environment, which enables service user’s to have access to all areas of the home and encourages independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was undertaken, with all areas of the home being visited, including service users bedrooms, bathrooms, toilets and communal areas. All of the bedrooms visited were seen to be well equipped and individually decorated, and evidence was seen of personal possessions. Both of the houses visited were of domestic proportion, and were clean and adequately decorated. One of the two houses had been partly redecorated, and was scheduled to undergo further refurbishment, the second house was due to Essex Care Consortium Colchester DS0000017838.V367052.R01.S.doc Version 5.2 Page 19 undergo some remedial work to brighten it up, prior to undergoing further development in a few months time. Both of the houses were however found to be homely and generally well maintained, and there was no evidence found in either of any unpleasant smells or odours. It was noted in one of the two houses that a toilet seat in one of the individual toilets was broken, and was potentially posing a health and safety risk to anyone who might use it, this was pointed out to the manager at the time, and they were heard to ask staff to enjoy that a request be made to have the repair carried out urgently. The garden areas were well presented and tidy, and at the time of the visit work was in progress to relay some of the pathways to make them wider and more accessible to service users who required the use of a wheelchair. On the day of the site visit service users were seen accessing the garden areas, although some areas were at the time out of bound due to the work in progress. As mentioned previously the home has it’s own allotment area, which service users, care for and look after, and take much pride in. The home’s laundry is situated at the rear of one of the houses and was equipped with industrial style washing machines and dryers, and was adequate to meet the needs of the number of service users in residence. Essex Care Consortium Colchester DS0000017838.V367052.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): 32, 33, 34, 35 and 36. Quality in this outcome area is good. People who use the service can be confident that they are cared for by a staff team who are trained and skilled to ensure that their identified needs are addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a dedicated Staff Training Officer. Discussion with the registered manager and staff, as well as sampling of the home’s staff training matrix indicated that since the last inspection the following training has been provided in the home: Medication administration, Physical interventions, inclusive communication, equality and diversity, mental capacity act, N.V.Q level 2, 3, and 4. Six pack training, which includes: appointed person’s first aid, health and safety, fire safety, adult protection, manual handling and food hygiene. Discussion with four members of the care team indicated that they felt access to staff training to be excellent. Essex Care Consortium Colchester DS0000017838.V367052.R01.S.doc Version 5.2 Page 21 Discussion with the manager and assistant manager indicated that newly appointed staff to the home are inducted over a twelve week period, the first two weeks purely focussing on policies and procedures, and completing the common induction standards, the next few weeks are spent shadowing more experienced staff, how long the shadowing period lasts is dependant upon previous knowledge and experience. The induction of new staff is based on the Skills for Care Common Induction Standards. Of the care staff employed in the home over 50 hold a National Vocational Qualifications (N.V.Q) at level two or above, this was confirmed by viewing of the home’s staff training matrix. Four staff files were sampled as a case tracking exercise to assess the service practice regarding recruitment. The recruitment practice for all four was sound, and included evidence of application form, two written references, criminal records bureau check, including POVA 1st check. As part of the home’s recruitment process the assistant manager provided additional records that are used as part of the process, these records included the use of a new recruits skills test, interview record, questionnaire, and assessment form, which were used to make any decision to recruit. Sampling of the home’s duty rota’s as well as from discussion with staff indicated that the staffing levels in each house are five in the morning and three in the afternoon, with nights being covered by two waking night staff. Discussion with these staff indicated that they felt the staffing levels in place were adequate to meet the needs of the number of service users in residence. Staff reported that they receive formal supervision bi-monthly, and that the system for providing them with supervision was good. Essex Care Consortium Colchester DS0000017838.V367052.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and42. Quality in this outcome area is good. The home ensures that the interests of people living there are central to the way the home is run. The health and safety of people living and working in the home are promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager has been in post for an established period and is both appropriately qualified and experienced. The management style within the service is, overall, well organised and delivered within a relaxed and supportive manner. The ethos is one of encouragement and pro-activity. Essex Care Consortium Colchester DS0000017838.V367052.R01.S.doc Version 5.2 Page 23 The organisation has achieved a standardised, externally validated, quality assurance scheme in addition to the Investors In People Award, and has in post their own quality assurance manager. Certificates were provided as evidence to confirm the above points. At the time of inspection the quality approach was focussed on service user meetings, which were taking place monthly, and were fully recorded. At each of the meetings National Minimum Standards are discussed. Copies of the minutes of the meetings are sent to the organisation’s quality manager. The registered manager reported that as part of the organisations continual review process the quality review process itself was undergoing a review. The registered provider carries out Regulation 26 visits on a monthly basis and provides the home with a copy of the reports. The service has fire detection systems, fire extinguishers, emergency lighting system, portable appliance checks and care of Substances Hazardous to Health (COSHH) strategy. Where appropriate, these systems are regularly checked by external contractors on a rolling basis. Safety certificates seen and found to be in order included: electrical installation certificate, environmental health officer report, records of fire drills, record of fire alarm tests, record of emergency lighting tests. On visiting all of the communal areas of the premises and the outside, no obvious health and safety matters were raised or were noticed. Essex Care Consortium Colchester DS0000017838.V367052.R01.S.doc Version 5.2 Page 24 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 4 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 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 X 3 x LIFESTYLES Standard No Score 11 X 12 4 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 3 X 3 X X 3 X Essex Care Consortium Colchester DS0000017838.V367052.R01.S.doc Version 5.2 Page 25 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 Essex Care Consortium Colchester DS0000017838.V367052.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Essex Care Consortium Colchester DS0000017838.V367052.R01.S.doc Version 5.2 Page 27 - 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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