Inspection on 08/06/07 for Gallimore Lodge

This inspection was carried out on 8th June 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 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gallimore Lodge 29/04/08

Gallimore Lodge 29/11/06

Gallimore Lodge 31/12/05

Gallimore Lodge 26/08/05

Gallimore Lodge 02/11/04

Gallimore Lodge 17/02/04

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

CARE HOME ADULTS 18-65 Gallimore Lodge Meesons Lane Grays Essex RM17 5HR Lead Inspector Trevor Davey Unannounced Inspection 8th June 2007 11:15 Gallimore Lodge DS0000015534.V335965.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 Gallimore Lodge DS0000015534.V335965.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. Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gallimore Lodge Address Meesons Lane Grays Essex RM17 5HR 01375 396174 01375 396174 gallimore.lodge@familymosaic.co.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) Family Mosaic Mrs Evelyn Thomson Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Excluding any person who is liable to be detained under the provisions of the mental Health Act 1983 29th November 2006 Date of last inspection Brief Description of the Service: Gallimore Lodge is a purpose built double bungalow situated on a private residential road in Grays. Public transport by both rail and bus is available approximately one mile away. The home has its own minibus. The accommodation consists of single bedrooms with lounge, dining room and kitchen facilities. Appropriate bathroom and toilet facilities are also available. The home has its own car parking facilities and a garden area is also made available for the use of residents. The home provides nursing and personal care for 8 adults with learning disabilities. Services provided include personal, psychological, social, emotional and educational care by a multidisciplinary team and enabling residents to remain as independent as possible. Residents are actively encouraged to participate in leisure pursuits within the local community but formal day care placements which were provided by the local Social Services Department, are no longer available. The Service User Guide and Statement of Purpose are available which are updated as required and are available for residents or their representatives. The current range of fees are between £63.95 and £98. 60 per week for rent charges and a block payment arrangement is in place with the local funding authority which covers the remaining fees. The Registered Provider also contributes £250 a year, (per resident) towards holiday expenses. Residents are responsible for extra charges to cover items such as hairdressing, newspapers/magazines and toiletries. Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection site visit covered a period of 7 hours and covered all Key standards. The Registered Manager together with other staff and residents were spoken with during the site visit. Their comments and contributions received were helpful in assisting the Inspector to prepare this report. As part of the site visit, a tour of the premises took place and some of the personal care records and other official records within the home were also assessed. The Registered Provider together with the management, had carried out a survey as part of the home’s quality assurance exercise. This is to find out what people think of the home and the service provided as well is helping the management to make improvements. Feedback of comments obtained from individuals were not available for inspection as these had been sent direct to the Head office. A summary of the overall outcomes of the quality assurance surveys was, however, on display in the entrance hall but this information represented all the care services for which the Registered Provider is responsible and not just Gallimore Lodge. This summary indicated that residents and their relatives were generally satisfied with the service provided and included many positive comments. It also showed that 85 felt that the senior staff kept residents and relatives updated as well is seeking their views. The Manager was in the process of completing an annual quality assurance assessment form (AQAA) which is to be shortly submitted to the Commission for Social Care Inspection. This form gives homes the opportunity of recording what they do well, what they could do better and what has improved in the previous twelve months as well including information of improvements planned for the next year. What the service does well: The staff of the home interact well with residents based on their individual assessed needs. Residents respond positively to staff who are able to use various communication skills as well as building up a good understanding and friendly relationships. This has been helped by the considerable knowledge of some of the staff team who have known and supported residents for a number of years which has assisted in providing improved stability and continuity. This is reflected in the personal assessment and care planning system. There is a homely atmosphere and the management are actively seeking to extend opportunities for residents to enjoy a greater variety of social and leisure activities. Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 6 There are good management structures in the home with effective delegation of responsibilities amongst the senior staff and other team members. Staff understand their particular roles and are supportive of one another to ensure the needs of residents are met. Areas for further training are identified and appropriate courses for staff are arranged. Ongoing maintenance within the building and servicing of equipment takes place to ensure health and safety issues are properly attended to. What has improved since the last inspection? What they could do better: Overall, personal care records, planning and the details shown have improved but there needs to be clear evidence of when reviews have taken place and even if there are no changes, this needs to be recorded and dated. The record of meals in the home, did not always include details of deserts provided for dinner which limits the evidence as to whether a balanced and nutritious diet is being provided to residents. There is still some inconsistency with the procedures used by the Registered Provider for dealing with recruitment records. Some information was available Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 7 in the home and other details were only available in the Head office. Information on application forms and references requested did not always correspond. New Criminal Record Bureau checks had not always been taken up. This means that residents could be at risk if thorough recruitment procedures are not carried out and recorded. It is of concern to the Inspector that this matter was discussed at the last inspection and the requirement included in the previous inspection report, has still not been met. Any future quality assurance surveys carried out by the home should include the views of other health care professionals as well as residents and their relatives. An action plan of improvement for the home should be prepared which relates specifically to feedback received for the service provided by Gallimore Lodge. 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. Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. Pre-admission assessment details for care/health needs had been completed to give staff suitable information and to assure potential residents that their needs could be met. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The majority of existing residents have been in the home for some time but more recent pre-admission assessment information inspected, included personal profile with photograph, background and social history including family information. Medical needs and contacts were recorded which included a summary of needs. This information had been gathered by one of the senior members of staff and also included a list of risks and how these could affect others. Likes and dislikes had been identified. The assessment process included a visit to the potential resident in their existing environment as well as visits to Gallimore Lodge prior to being admitted. Information provided by physiotherapists had also been included. There was evidence to show that the personal aspirations and needs of residents had been taken into account and Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 10 that where appropriate, relatives and other health care professionals had been involved in this process. Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 11 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 & 9 People who use the service experience good quality outcomes in this area. Residents benefit from continual assessment and consultation reflecting the changing needs which are identified in individual plans. Independent lifestyles are encouraged which are accompanied by risk assessments. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Care plans sampled, showed identified needs which also took into account care plans previously prepared by social workers involved with the admission process. These had been updated and included support plans which were detailed to reflect personal preferences of residents as to how they wished staff to support them. Key workers had also been involved in writing four- weekly support plan reports which had been signed and dated. Risk assessments inspected were detailed and properly recorded and covered areas such as the use of bed rails which had been recently reviewed as well as measures needed Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 12 for the prevention of choking. The home receives good co-operation and input from other health care professionals such as physio and occupational therapists. Although several of the residents experienced communication difficulties, the staff team were observed to be interacting well and responding appropriately. Makaton, pictured boards and symbols are all used to assist in this process. During the inspection residents were observed taking part in their own chosen activities which included spending time in the sensory room, talking to their friends and staff and involvement with puzzle games. The staff also supports residents in taking part in other activities they enjoy in and around the home such as helping in the office. Social workers from funding authorities visit annually to review the care and support provided and to record outcomes to ensure needs are being properly met. Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 & 17 People who use the service experience good quality outcomes in this area. People living at the home are encouraged to take part in a range of activities which reflects a lifestyle to meet individual social and cultural needs. People living in the home are involved in choosing their meals which are nutritious and varied. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Residents are encouraged to take part in a variety of recreational and leisure activities which include visits to shopping centres, local markets and restaurants. As well as regular hairdressing appointments, staff assist some of the residents who enjoy hand massage and manicures. A timetable of activities which has been produced in picture form, is displayed in residents’ bedrooms. Additional staff hours have been made available since April to Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 14 enable residents to be taken out on a more regular basis to local shops, the beach as well as having more recreational time with residents in the home. Residents choose their own activities which includes painting, colouring as well as making use of the sensory room. There are also opportunities for some of the residents to be involved with staff in cake making as an extra activity. The home also has its own transport and staff talked about other possibilities they were exploring for increasing the variety of social and recreational activity. The Inspector was advised that there are also six joint social functions arranged each year by the Registered Provider involving residents from all the care homes. Whilst having additional staff hours is beneficial for the residents, staff spoken with, felt it is sometimes difficult to maintain this social input when staff take annual leave or have other commitments such as accompanying residents for health care appointments. Staff commented that residents miss not being able to attend the day services which were provided by the local Social Services Department as these are only now available for people who live in the community. Attendance at the local college is now restricted to people who are under 25 years of age. Picture menus and boards were available in the dining rooms to help with communication when discussing choice of meals. The menu included a variety of meals which included a choice of cereals, fresh or dried fruit and toast for breakfast. A full cooked breakfast is available at weekends. There is a choice for lunch and dinner. It was noted that the record of meals did not always include details of the deserts which had been provided on certain days. From the sample checks made, this information had been omitted for different days of the week i.e. Saturday, Monday, Tuesday, Wednesday and Friday. Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 People who use the service experience good quality outcomes in this area. The personal, physical, and emotional health needs of residents were being met appropriately taking account of preferred support required. Medication and administrative procedures were in place to ensure the safety and protection of residents. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Care plans inspected included recorded information relating to personal care, dietary needs and oral hygiene. As part of the support plan, this included a variety of information in respect of individual residents such as seating positions and posture with regard to the use of the mechanically aided chairs and the personal preference of residents as to how they wished staff to support them through these manoeuvres. Other care plans included information regarding the use of catheters, involvement of community nurses as well as clinical and technical information to assist staff. The Inspector was advised that Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 16 reviews regularly take place but it was noted that where there was no change identified in the care support to be provided, this had not always been supported by any recorded documentation on the care plan. There needs to be some evidence that a review has taken place and of the decision agreed indicating that the current plan of care is to continue. Where physio or occupational therapists had been involved, their comments had been recorded as well as advice regarding special equipment such as wheelchairs. Staff are aware of infection control procedures including the use of disposable gloves, aprons and waste disposal arrangements. Members of the staff team are also key workers to individual residents and they advised the Inspector that this involves taking responsibility for personal toiletries, looking after bedrooms, maintaining care plans and taking residents out. Staff were observed to be both sensitive and reassuring in the support they gave to residents who were in the home at the time. During the morning of the inspection, two of the staff team were out with some residents who required dental appointments. A sample check was made of the medication administrative records (M.A.R.) which had been completed in accordance with accepted procedures. Staff stated that local doctors were very responsive and supportive. Where transcribing of medication details had been recorded, these had been supported by two staff signatures. A record of discontinued drugs which had been returned to the pharmacist was available for inspection. Protocols for P.R.N. (to be taken as required) medication were in place for individual residents. Medication was seen to be stored appropriately and secure. Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 &23 People who use the service experience good quality outcomes in this area. People who use the service have the opportunity to express their concerns and have access to a robust, effective complaints procedure, are protected from abuse and self harm. This judgement has been made using available evidence including a visit to the service. EVIDENCE: An effective complaints procedure is in place which is also displayed in picture form in individual bedrooms. There had been no complaints recorded since the last inspection. Staff spoken to were aware of the prevention of harm to vulnerable adults reporting procedures to be followed in cases of abuse of suspected abuse. Copies of these policies and procedures were available and staff had attended training provided by the local Social Services Department. Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use the service experience good quality outcomes in this area. The premises are well maintained to enable people who use the service to live in a safe, comfortable environment. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The premises were clean, hygienic and odour free with regular maintenance taking place of services and equipment. The bedrooms, lounges and dining room facilities are comfortable and suitable for the needs of residents in the home. The premises are suitably decorated with bedrooms furnished and personalised to meet individual needs and preferences. Residents are given the opportunity of choosing their own bedding and colour schemes and in some cases, relatives have provided curtains. Some of the carpets within the home had been replaced since the last inspection. Easy access is available throughout the building which is suitable for residents who are wheelchair Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 19 dependent. Risk assessments had been completed for a safe working environment which included the safe working of electrical equipment, reducing cross infection and the handling and disposal of clinical waste. Gallimore Lodge DS0000015534.V335965.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 People who use the service experience adequate quality outcomes in this area. Staff in the home are trained, skilled and in adequate numbers to support people who use the service. Recruitment policies and practices are not adequate to ensure residents are properly supported and protected. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The Registered Manager leads the staff team with four deputy senior staff. Each deputy takes responsibility for the support workers on a rota basis and draws up care plans for the staff team to follow. In addition, deputies take responsibility for reviewing care plans and risk assessments together with other delegated responsibilities in the home. Staff rotas were available and the normal ratio provides for one qualified nurse and two support workers to cover the early and late shifts. The Manager is normally available in the home Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 21 from 7:a.m. till 4:30 p.m. Since the beginning of April, the Registered Provider has increased the staffing establishment for support workers and additional hours are available from 9 a.m. to 4:30 p.m. five days per week. This is to enable sufficient cover to be available to support residents who wish to pursue leisure activities in the community as well as keeping health and hospital appointments. This has been necessary since the provision of day-care and college facilities in the local area have been withdrawn for people in residential care. Two staff are on awake duty at night. Although staffing levels have recently been increased, there has been no additional provision to allow for cooking, the preparation of meals and cleaning duties all of which, are carried out by the existing staff team. The Registered Provider should constantly review staffing levels bearing in mind the high dependency levels of residents in the home. Some of the staff spoken with during the inspection, mentioned that although it has been good that additional staff hours have been granted since April, it can still be difficult to ensure residents are supported regularly in the community when members of the team are absent because of sickness or annual leave. Training records were available and staff spoken with confirmed that they had attended moving and handling, Makaton, fire and infection control, communication and medication courses. Some staff are studying N.V.Q. Level 2/3 courses. Arrangements have been made for staff to attend an inclusive communication course which is for five days part of which is in the home itself. Teaching and assessing in clinical practice training has also been made available to staff. Certificates awarded to staff for courses completed were available. A consistent approach is not being followed by the Registered Provider in relation to staff recruitment procedures. This was highlighted in the previous inspection report. In March 2006, the Registered Provider made an agreement with the Commission for Social Care Inspection that recruitment records would be available for staff of the Commission in their Head office or records could be couriered to the care service within two hours for inspection. At the request of the Inspector, one of the files was brought to the home for checks to be made. This showed that no reference had been obtained from the previous employer and a new Criminal Record Bureau check had not been applied for. There was no evidence or proof of identity. Recruitment records for other staff were available in the home but in some cases information provided was not clear in relation to information on the application form and references taken up and whether this included the previous employer. As these issues have been raised previously by the C.S.C.I. with the Registered provider, urgent action must be taken to ensure that recruitment procedures are robust, effective and consistent as vulnerable residents could be at risk unless these procedures are implemented in accordance with Regulation. Gallimore Lodge DS0000015534.V335965.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 & 42 People who use the service experience good quality outcomes in this area. The management and administration of the home is based on openness, and respect but needs to develop its quality assurance system. Procedures are in place to monitor the health, safety and welfare of residents. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The Registered Manager is experienced, qualified nurse and has completed the N.V.Q. Level 4 Registered Manager’s Award. Refresher courses have also been completed. Staff spoken with confirmed that regular meetings take place with both staff and residents and that all the staff team receive regular supervision. Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 23 The management of the home were said to be supportive and the staff team communicate well together. Regular monthly monitoring visits are made on behalf of the Registered provider and reports were made available for inspection. Health and safety in the home was being regularly monitored with service agreements being periodically reviewed including gas and electrical safety certificates, servicing of hoists and other mechanical equipment. Fire safety procedures had been regularly checked and reviewed. Staff were also aware of regulations relating to control of substances hazardous to health. Evidence of up- to -date employers liability insurance was seen. The home half currently completing quality assurance surveys for this year and copies are to be sent to the C.S.C.I. The overall outcomes of quality assurance surveys were on display in the entrance hall but this summary covers all the care home services within the Organisation and does not separately identify the outcomes for Gallimore Lodge. From this overall summary, there was general satisfaction with the service provided with many positive comments although concerns had been expressed over the cutting of day care services and educational facilities in the community. The Registered Provider stated in the summary, Your comments will be taken on board and we will endeavour to address these to improve services. There was no indication, however, of whether an action plan had been agreed setting out the steps to be taken to bring about improvement, how these were to be achieved and timescales. It would also be helpful in future surveys to include the views of other health care professionals who visit and have involvement with the service. This would give a wider perspective and more comprehensive feedback as to how the service is meeting the needs of residents. Gallimore Lodge DS0000015534.V335965.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 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 1 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 25 YES 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. 1. Standard YA34 Regulation 17(3b) Sch 4(6) 19 Requirement The Registered Person shall not employ a person to work at the care home unless thorough recruitment checks have been completed to determine their fitness. This includes taking up written references & new C.R.B. checks. (Previous timescale of 08/01/07 not met). Timescale for action 31/08/07 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. 2. 3. 4. Refer to Standard YA17 YA18 YA33 YA39 Good Practice Recommendations Records of individual meals provided to residents should include more details. A record of reviews carried out of care plans/risk assessments should be noted even if there are no changes. Additional staff should be made available to ensure the holistic needs of residents can be met at all times. Quality assurance surveys should take into account the views of health care professionals who are involved with the service. DS0000015534.V335965.R01.S.doc Version 5.2 Page 26 Gallimore Lodge 5. YA39 Following completion of the quality assurance exercise, an action plan should be drawn up for the home setting out how improvements are to be met with timescales for implementation. Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Gallimore Lodge DS0000015534.V335965.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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