Inspection on 31/10/06 for Greensleeves

This inspection was carried out on 31st October 2006.

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

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

Other inspections for this house

Greensleeves 17/09/08

Greensleeves 17/01/06

Greensleeves 14/07/05

Greensleeves 25/02/05

Greensleeves 06/05/04

Greensleeves 13/06/03

Greensleeves 05/08/02

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

CARE HOME ADULTS 18-65 Greensleeves Friday Street Eastbourne East Sussex BN23 8AP Lead Inspector Nigel Thompson Unannounced Inspection 31st October 2006 09:30 Greensleeves DS0000021121.V310314.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 Greensleeves DS0000021121.V310314.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. Greensleeves DS0000021121.V310314.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greensleeves Address Friday Street Eastbourne East Sussex BN23 8AP 01323 461560 01323 763723 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) Eastbourne & District Mencap Mr William Barnfield Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Greensleeves DS0000021121.V310314.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is eleven (11). Service users must be aged between forty (40) and sixty-five (65) years on admission. Service users with a learning disability only to be accommodated. A maximum of two service users with a mental disorder in addition to having a learning disability can be accommodated. 17th January 2006 Date of last inspection Brief Description of the Service: Greensleeves is one of three registered care homes for adults with learning disabilities provided by Eastbourne and District Mencap. The home is registered for 11 adults with learning disabilities and service users may remain in the home into old age. The home is a large detached extended bungalow that provides seven single bedrooms and two double bedrooms all with en-suite facilities. There is a chair lift to access the first floor. There is a separate lounge and dining room and a large kitchen that opens onto a patio area and a large rear garden that has recently been landscaped and is now much more accessible and safer for service users. Greensleeves continues to provide a safe and happy environment whereby people can learn to live as independently as their disability will allow. Service users are enabled to access college courses, day centres and a range of leisure activities, both within the home and in the local community. Information about the service, including the Statement of Purpose, Service User’s Guide and CSCI reports is made available to prospective service users or their relatives, on request, as part of the admission process. The current fees at Greensleeves, as of 31 October 2006, are £583.36 per week. Greensleeves DS0000021121.V310314.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over three and a half hours in October 2006. It found that all of the National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. Service users spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. The purpose of this inspection was to monitor care practices at the home. On the day of the inspection there were eleven service users living at the home. The inspection involved a tour of the premises, examination of the home’s records and discussion with the Registered Manager. Two members of staff and five service users were also spoken with. The focus of the inspection was on the quality of life for people who live at the home. Responses from a CSCI service users’ survey, regarding their views on the home and quality of care provided, now form part of the inspection process and have also been included in this report. What the service does well: Service users at Greensleeves clearly benefit from having an experienced manager and dedicated staff team who are evidently committed to providing consistent and high quality care. Staff work closely with service users and have developed a sound understanding of their individual care and support needs. The relaxed, homely and welcoming environment has evolved over several years and reflects the stability and commitment within the staff team and the open and inclusive management style. Service users are encouraged and supported to make decisions about their lives. They are involved and regularly consulted on many aspects of life in the home, including menu planning and activities. Communication and consultation with service users’ family members is also effective and ongoing. Relatives have the opportunity to partake in individual assessment, care planning and reviewing processes. Staff receive effective induction and foundation training, regular supervision and are clearly valued and supported by the manager. Greensleeves DS0000021121.V310314.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Greensleeves DS0000021121.V310314.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 Greensleeves DS0000021121.V310314.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The thorough admission policy and procedure ensures that service users are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. Prospective service users know that the home is able to meet their individual care and support needs. EVIDENCE: Information is available to prospective and existing service users in various formats. The Statement of Purpose and Service User Guide have been thoughtfully and imaginatively produced to a high standard and are both comprehensive and informative. It was noted that the Statement of Purpose has been revised and updated since the previous inspection to reflect the recent managerial changes, which has seen the deputy manager leave the home to take up another position within the organisation, based at the head office. Outdated references to and contact details for the National Care Standards Commission (NCSC – the previous organisation responsible for regulating care services), noted in the Operational Policy and the Terms and Conditions, were immediately amended once they were brought to the attention of the manager. Greensleeves DS0000021121.V310314.R01.S.doc Version 5.2 Page 9 Although the manager confirmed that there have been no admissions to Greensleeves for over four years, there was evidence of a clear and thorough admission policy and procedure being in place. As part of this procedure, a detailed pre-admission assessment form has been developed and includes information relating to the individual’s personal, medical, social and psychological care and support needs. Prospective service users and their relatives are encouraged to visit the home and have the opportunity to look around and meet with members of staff and existing residents. The manager confirmed that new service users undergo a six month trial period at the home, during which time their suitability and compatibility are assessed and it is established whether their identified care and support needs are able to be met. Greensleeves DS0000021121.V310314.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Comprehensive care plans enable staff to meet the assessed support needs of service users in a structured and consistent manner. Systems for consultation and participation are effective. Service users are treated with respect and encouraged and enabled to make decisions about their day-to-day living. EVIDENCE: High quality, ‘person centred’ care plans have been developed for each service user, clearly linked to the individual’s assessed needs. The plan is formulated by the key-worker, manager and evidently with the direct involvement of the service user or family member, as appropriate. Staff spoken to during the inspection confirmed that, despite the variable and limited verbal communication of some service users, effective and regular interaction and consultation takes place constantly throughout the home. This was evident from direct observation of staff supporting service users in a professional, sensitive and respectful manner. Greensleeves DS0000021121.V310314.R01.S.doc Version 5.2 Page 11 The manager confirmed that service users’ care plans are formally reviewed every six months to ensure that the individual’s care and support needs continue to be met in a structured and consistent manner. However in addition to this, all service users are discussed in detail at monthly staff meetings. Any significant changes are addressed immediately, as in the case of a service user who had suffered a stroke and it was evident that specific staff training had been organised immediately, to ensure that appropriate support was able to be provided. In care plans that were examined, there was clear evidence of the direct involvement of the service user or a relative in the reviewing process. It was noted that a ‘Consent form’ had been signed to acknowledge agreement with the content or to any changes to the plan The manager emphasised the importance of staff developing close working relationships with individual service users and being aware of often subtle changes in their mood or condition. Service users are clearly consulted regarding many aspects of their day-to-day living, including menu planning and choosing both individual and collective social, recreational and leisure activities. It was noted that ‘Communication guidelines’ have recently been developed in respect of several service users with limited communication, including a visual or hearing impairment. The guidelines are written in the first person and make effective use of photographs to ensure that staff are aware of the individual’s current physical and psychological condition and of their ongoing care and support needs. Greensleeves DS0000021121.V310314.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are enabled and supported to maintain contact with family and friends as they wish and effective links with the community enrich their social and educational opportunities. Service users benefit from appropriate recreational and leisure activities and menus that are balanced and nutritious, reflecting their individual likes and preferences. EVIDENCE: The manager confirmed that, where appropriate, service users’ family links continue to be supported, however not all service users have regular family contact. Community participation remains a focus in the home and service users are evidently encouraged and supported to visit the cinema, theatre, local shops and other amenities. Following consultation with service users, a popular local restaurant has recently been booked for the Christmas meal. Greensleeves DS0000021121.V310314.R01.S.doc Version 5.2 Page 13 The recreational and leisure interests of service users are identified and recorded in their individual care plan and they continue to be supported to access activities and facilities, reflecting their individual needs, preferences and abilities. A weekly programme of day service activities is displayed in the office and a notice board is updated daily with the schedule for the day, including specific times for individual appointments and collections. Individual care plans examined and comments from staff and service users confirmed that activities include craftwork, music sessions, attending a local college and other day services, various trips out and a variety of other leisure activities. Two service users are members of a local theatre group and continue to regularly take part in amateur dramatic productions. The four week rolling menus are varied and balanced and are based on service users’ identified likes and preferences. An alternative to the main meal is always available and a copy of the menu is displayed in the kitchen. A member of staff confirmed that, where appropriate, service users are sometimes involved in meal preparation. This was confirmed by one service user, spoken with during the inspection: ‘I like helping in the kitchen’. Greensleeves DS0000021121.V310314.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff have developed close and positive relationships with service users and demonstrate an awareness and sound understanding of their individual care and support needs. Service users are protected by clear and comprehensive policies and procedures in place for the control and safe administration of medication. EVIDENCE: In accordance with their care plan, service users are fully supported and enabled, as far as practicable, to exercise control over their lives and maintain maximum levels of independence and individuality. During the inspection, staff were observed interacting with service users in a professional and respectful manner. Documentary evidence was in place to demonstrate that the health and emotional care needs are continuing to be met within the home. All service users are registered with local GPs and have access to other health care professionals, including district nurses, physiotherapists and dentists, as Greensleeves DS0000021121.V310314.R01.S.doc Version 5.2 Page 15 required. It was noted, in care plans that were examined, that all appointments with, or visits by, health care professionals are recorded. Greensleeves continues to operate an effective key worker system and staff were observed working closely and sensitively with service users to meet their identified personal care and support needs. As previously documented, following consultation with service users, specific guidelines have been developed for all staff, ensuring that support is provided in a structured and consistent manner and in a way that the individual prefers. Staff spoken to during the inspection confirmed that service users are supported to access a range of health care professionals in the community. The home continues to work closely and effectively with the Community Learning Disabilities Team, which provides support and guidance in addressing service users’ psychological healthcare needs. Up to date, detailed policies and procedures relating to the control, storage, administration and recording of medication are in place. Medicines are stored and recorded appropriately. All staff responsible for administering medication have received training and are individually assessed and authorised to do so. The manager confirmed that, following risk assessments, one service user continues to self-administer their own medication. As with all risk assessments, this situation is kept under regular review. The home uses a monitored dosage system (MDS) for the administration of prescribed medicines and a local pharmacist continues to carry out quarterly monitoring visit. In house staff training is provided in the control and safe handling of medicines. Controlled drugs are stored and administered appropriately. Greensleeves DS0000021121.V310314.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The open and inclusive atmosphere and effective communication systems within the home enable service users, staff and visitors to feel able to express any concerns, confident that they will be listened to and acted upon. Service users are safeguarded from abuse through relevant staff training and robust policies and procedures. EVIDENCE: An up to date complaints procedure is in place in the entrance hall for the benefit of service users’ relatives and other visitors to the home. All complaints are recorded and include actions taken and outcomes achieved. However, it was noted that there have been no formal complaints received by the home since the last inspection. The manger confirmed that service users’ meetings are held on a regular basis and provide an opportunity for any concerns to be raised and discussed before they become complaints. Service users and members of staff, spoken with during the inspection, confirmed that they would have no hesitation in speaking to the manager or making a complaint if necessary and each person was confident that they would be listened to. Greensleeves DS0000021121.V310314.R01.S.doc Version 5.2 Page 17 The organisation has produced detailed policies and procedures relating to adult protection and abuse, including a whistle blowing policy. Staff have undertaken specific adult protection training, in accordance with the multi agency guidelines for the protection of vulnerable adults. This was supported through discussions with members of staff during the inspection and evidenced through individual training records. The manager confirmed that in December all staff are due to undertake further training, specifically relating to ‘Whistle blowing’ and including procedures for alerting. Greensleeves DS0000021121.V310314.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The service is accessible, safe and clean and remains clearly suitable for it’s stated purpose. Service users benefit from all necessary specialist equipment and pleasant accommodation that is comfortable, well maintained and decorated to a satisfactory standard. EVIDENCE: Greensleeves has been purpose built to a high specification and clearly meets service users’ individual and collective needs. The physical environment of the home remains largely unchanged and the well maintained décor and good quality furniture and furnishings provide a comfortable, pleasant and homely environment for service users. The manager confirmed that individuality and independence continue to be promoted within the home, as far as is practicable. This was evident from the personalising of service users’ rooms, which clearly reflects individual tastes, preferences and interests. Greensleeves DS0000021121.V310314.R01.S.doc Version 5.2 Page 19 Following my guided tour of the premises and subsequent discussion with the manager, it is recommended that consideration be given to providing a screen in one of the shared rooms, to allow more privacy and dignity for a service user who now requires an increased level of personal care. Positive comments from service users, spoken with during the inspection, reflected a high level of satisfaction with the home and the services provided: ‘I’m very happy here and I like my room’. As with many of the environmental standards, the situation at Greensleeves regarding shared space remains largely unchanged. Adequate communal areas are provided to meet the individual and collective needs of the service users, including a pleasant dining room and a spacious lounge. All communal areas are decorated and furnished to a high standard. Furniture and lighting throughout the home is domestic in character All necessary specialist equipment is made available to meet service users’ assessed mobility needs, including assisted baths, wheelchairs and hoists. The home also provides a chair lift and there are grab rails in bathrooms, toilets and corridors. Levels of cleanliness and hygiene remain high throughout. Infection control procedures are in place and closely adhered to. A programme of routine maintenance, renewal and redecoration is in place. Greensleeves DS0000021121.V310314.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are protected and benefit from the home’s recruitment policy and procedures and from sufficient trained, competent and appropriately supervised staff on duty at all times to meet their assessed care and support needs. EVIDENCE: The stable and dedicated staff team remains clearly able to meet the assessed, individual and collective needs of service users within the home. All new employees are provided with a comprehensive job description and staff spoken demonstrated a sound understanding of their individual role and responsibilities. All new staff receive comprehensive induction and foundation training, the ‘Common Induction Standard’, which is compatible with Skills for Care (Formerly TOPSS) and is flexible and compatible with an individual’s level of relevant experience. Mandatory training is ongoing and is recorded in individual staff files. This was confirmed through discussions with staff and supported by training records examined: Greensleeves DS0000021121.V310314.R01.S.doc Version 5.2 Page 21 ‘There is so much opportunity for training here’ There are currently six care staff who hold the National Vocational Qualification (NVQ) level 2. The manager is clearly aware of the need for thorough and robust recruitment procedures, to ensure the protection of service users. Individual files that were examined, relating to recently appointed members of staff, were found to be well maintained, containing all relevant and necessary information, including two satisfactory references, proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. The manger confirmed that service users continue to be actively involved in the recruitment and selection process and meet with all prospective members of staff. In accordance with organisational policy, formal supervision is provided for all care staff on a regular basis. Since the recent departure of the deputy manager, the manager confirmed that he now undertakes all supervision sessions. This was evidenced by supervision records examined and through discussions with staff, spoken with during the inspection, who acknowledged the benefits of effective supervision and confirmed feeling valued and supported by the manager: ‘Supervision is very useful and the manager is always very supportive’. It is evident, from discussions with members of staff that the manager also operates an ‘open door’ policy, with staff feeling confident and able to discuss any issues at anytime. Greensleeves DS0000021121.V310314.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users benefit from effective management, comprehensive quality monitoring systems and are protected by thorough health and safety checks and guidelines and efficient record keeping. EVIDENCE: From direct observation and through discussions with service users and members of staff, it is evident that the manager continues to demonstrate a clear sense of leadership and direction. He is clearly motivated, positive and approachable and continues to create an open and inclusive atmosphere within the home. As previously documented, since the last inspection the deputy manager has left Greensleeves to take up another position based at the Head Office. Greensleeves DS0000021121.V310314.R01.S.doc Version 5.2 Page 23 The home continues to operate effective quality monitoring systems, including satisfaction questionnaires for both service users and their relatives. The manager confirmed that the health, safety and welfare of service users and staff remain of paramount importance within the home. The recently departed deputy manager is now responsible, amongst other things, for developing and implementing policies and procedures relating to health and safety issues across the organisation. Staff training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. All staff training is recorded. COSHH assessments and guidelines are in place. Regular fire drills are undertaken and recorded. It was noted that the most recent drill was carried out in July this year. Temperature regulators are fitted to all hot water outlets, accessible to service users. All accidents, incidents and injuries are recorded and reported, as required. Greensleeves DS0000021121.V310314.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 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 3 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 X X 3 3 Greensleeves DS0000021121.V310314.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. 1. Refer to Standard YA25 Good Practice Recommendations It is recommended that consideration be given to providing a screen in one of the shared rooms, to allow more privacy and dignity for a service user who now requires an increased level of personal care. Greensleeves DS0000021121.V310314.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Greensleeves DS0000021121.V310314.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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