Inspection on 06/09/07 for Grove Court

This inspection was carried out on 6th September 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 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

Grove Court 18/01/07

Grove Court 05/10/05

Grove Court 19/04/05

Grove Court 17/11/04

Grove Court 16/06/04

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

CARE HOME ADULTS 18-65 Grove Court 100 Lancaster Road Newcastle Staffordshire ST5 1DS Lead Inspector Mr Berwyn Babb Key Unannounced Inspection 6th September 2007 01:30 Grove Court DS0000004950.V348029.R02.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 Grove Court DS0000004950.V348029.R02.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. Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grove Court Address 100 Lancaster Road Newcastle Staffordshire ST5 1DS 01782 628983 01782 714982 grovecrt@rethink.org www.rethink.org Rethink 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) Karen Leslie Howells Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (14) Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 14 MD - 25 years on admission. Date of last inspection Brief Description of the Service: Grove Court is a large Victorian building located in a residential area close to Newcastle town and with good access to public transport. It was opened in 1991 and is run by the Rethink Organisation. The accommodation is on three floors, with a lift to access some bedrooms on the first floor. On the ground floor, there is a large lounge dinning room, a dining room, which is also used as the smoking room, kitchen two bedrooms and toilet facilities. The laundry is located in the basement. The first and second floors have bedrooms and toilet facilities, in total there are six single and four shared bedrooms some have en-suite facilities. One bedroom for one person who is more independent, is in the annex within the garden of the home; it has good facilities including an en-suite shower. The home accommodates up to 14 people with enduring mental health issues. This is provided in a supportive environment with support from specialist primary care and hospital health professionals. The aim is to maximise independence, promote an increased quality of life and provide individuals with an opportunity to develop living skills and have a positive community presence. Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out during the afternoon of Thursday the sixth of September by one inspector working alone. He was able to meet with and talk to all of the people who use the service, and to both the registered care manager and her deputy, and other members of staff. He also had a long discussion with a Community Psychiatric Nurse who was visiting one of her patients that afternoon, and who was extremely positive about the contacts she had in relation to this home. A cursory visual examination was made of the exterior, and all parts of the grounds were visited. All communal and service areas of the home were visited, as were a sample of the bedrooms of people who use this service, (mainly in the company of those people who had given their permission for their rooms to be examined, and who took the opportunity to use this time to tell the inspector about themselves, and about their lifestyles). Further input for this report was gleaned from reviewing a sample of care plans, and other documents kept in the home, such as; Training matrix, Menus, Staff rotas, Fire safety and Fire prevention records, General servicing records for such things as hoists, electrical equipment, fire fighting equipment, central heating, and the lift. (This was out of order awaiting a new parts that had been promised for the previous day, and which actually arrived as the inspector was leaving the home, so he spoke to the service engineer who was about to fit it, as a result of which, no requirement will be made over this unavailable facility). A formal interview was undertaken with a member of staff, which taken with the comments of those people who use the service, made a very favourable impression of how this home is run. The current level of fees were given as being between £294 and £314, with people who use the service purchasing personal choice items, such as ice cream, newspapers, and magazines and smoking materials, out of their personal allowance. What the service does well: Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 6 This home continues to provide security and a safe environment for up to 14 adults who have continuing mental health needs. It does this in a property that has no outward stigmatisation of being an institution, and with in a residential area that is conveniently situated near to all the facilities of the market town of Newcastle. 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. The summary of this inspection report can be made available in other formats on request. Grove Court DS0000004950.V348029.R02.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 Grove Court DS0000004950.V348029.R02.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, 2, 3, and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective users of the service were seen to have their needs assessed, their choices recorded, and to be informed of the ability of the home to meet these, and to then benefit from graduated introductory visits to make their admission as trauma free as possible. EVIDENCE: A sample of care plans was reviewed to establish that people entering this home had benefited from the recognised procedures. In one persons pre admission documentation it was recorded that he had experienced an expanding programme of visits to the home culminating in an overnight stay, before taking the decision to negotiate permanent admission. Other peoples care plans recorded lunchtime visits, and discussion with people who use this service, and with the professional who was visiting her home at the time of the inspection, confirmed the very high quality of work being done to assess the needs and personal choices of prospective residents, and to confirm with them the ability of the home to work with them to meet these needs and choices. Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service can know that their are assessed and changing needs are reflected in an individual care plan that includes their personal goals. They can receive assistance to help them make decisions about their lives, and be consulted about all aspects of the service, whilst being assisted to maintain the most independent lifestyle possible, even to the extent of being supported to take acceptable risks. EVIDENCE: In the sample of care plans examined the quality of the review sheet was particularly worthy of note as it not only included a goal agreed with the person who use the service, but also contained provision for them to record their own comments on all aspects of their care. Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 10 This was followed with a section for the individual to be able to say whether they were happy to continue taking their medication. (They were also encouraged to say whether they were having any of the known side effects, and to comment on any other experiences they may be having as a result of taking this medication.) Some of the goals identified by individuals for their future, included one person who wanted greater contact with his dentist, another person who said: I want to be able to maintain my independence , and another who said: I want to have the opportunity to carry out the things that I find most enjoyable, especially to be able to stay safe whilst Im travelling . Tellingly, one person had said: I want my seizures to remain controlled . In one persons plan, the appreciation of what it meant for them to live with a particular aspect of their condition was demonstrated by a referral that had been made for them to the organisation, Borderline Voices. The way the information about what happened in the life of the individual was recorded in these plans, was felt to be helpful and informative, especially to those people working on subsequent care shifts, as it provided them with a good basis for being able to meet each persons needs and choices. In conversation with the inspector, people who use this service identified instances where the personal choices had either been met immediately, or where they had been assisted through the provision of staff assistance or more individual training, to de-escalate any risks that these posed, to a level where they became acceptable. Examples given included programs of familiarisation with the locality to enable people to access it independently, support to obtain bus passes and to plan journeys, and some intensive work on ensuring that behaviour towards other people in public places was of an acceptable nature, and not likely to cause offence, or to bring the individual into conflict with others, and with the law. It was confirmed with the Registered Care Manager that House meetings took place with the people who use this service, and a visual review was undertaken of questionnaires filled in by them, to measure their satisfaction with the service being provided. Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service were assisted to take part in valued and fulfilling activities, access, and be part of, the local community, have appropriate leisure activities, maintain relationships and make new ones, and to have a nutritious and wholesome diet, that met with both their individual needs, and personal choices. EVIDENCE: Review of a sample of care plans taken together with the confirmation of people who use this service, identified that they were engaging on a regular basis in a mixture of independent, [more socially orientated], activities, and those provided by establishments associated with their known health conditions. Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 12 For the majority of the people who use this service, mainstream employment would not be a realistic option, but some of them shared their experiences of activities they engaged in during the day, including three who are members of the local gym, and go there regularly to work out. They listed shopping and visiting the local pub as examples of how they participated in the community, and how they had made use of money from their Welfare Fund, [which included donations from the Sentinel Newspaper group], to hire a coach for trips out, the most recent being too founded no. (At the request of one person, which was then supported by the others, future arrangements are being made for a trip to Porthmadog before the autumn is too far progressed. Other sources of funding have come from holding a summer fete at the home, and people said how much they enjoyed being involved in the organisation of this, and meeting the different members of families and the neighbourhood who supported them on the day. One person was particularly thankful that money from this source had been available to purchase tickets to go to the local Regent Theatre, because they enjoyed watching plays. Staff confirmed that money from this source was also used to hire minibuses for smaller outings, and to pay for flowers which one person particularly likes to have fresh in the home, to pay for parking for the minibus when they arrive at various destinations (which can apparently be quite expensive, around £10 a time) and towards social events such as the Christmas party. Not everybody had family involvement, but one gentleman talked particularly about his contact with his mother, and another about telephone calls to members of his family. Discussion took place with staff over the involvement of befrienders, which they had found to be an extremely positive way of expanding the support network of those people without active family ties. The evening meal was being prepared during the inspection, and people who use the service expressed their enjoyment of it, as well as saying how much they enjoyed the freedom to indulge in take-aways, and also the passion of one person, for ice cream. (Provision has been made of a separate fridge for the people who use this service, so that in addition to the ice cream provided by the home, they can keep separately those supplies purchased by themselves out of their personal allowances. Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 13 Food was discussed with the registered care manager who provided a copy of the basic menu that has been devised for the four-week rotation, and this showed a good variety of meals that were appropriate and included both seasonal vegetables and local delicacies. She stated that they always started with a menu as a guide, but that there were many times when peoples individual or collective wishes resulted in this being changed, especially when there was a group decision to have a Take-Away Evening . A visit to the kitchen found this to be clean, tidy, and well ordered, with storage vessels and utensils in good condition, and a variety of foodstuffs kept in reserve to supplement the regular shopping trips that were undertaken, as part of many peoples ongoing community access programs, and indeed, their pure social enjoyment. Grove Court DS0000004950.V348029.R02.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. This judgement has been made using available evidence including a visit to this service. People who use this service either administer their own medication or receive it from appropriately trained carers, and enjoy flexible personal support in a manner of their own choosing, and have their health care needs met in line with current best practice and their known and emerging conditions. EVIDENCE: One person in the home told Inspector that he liked to go to bed at a certain time, and that he was assisted to do this, even to the extent of extra staff input from those on overnight duty, as it caused him to wake very, very, early in the morning. The member of staff engaged in a formal interview told Inspector about another person did not actually like having a bath, but had become so used to having it at the same time every week in hospital, that this was now part of a fixed routine from which he did not wish to deviate. It was also his choice that she should be the one person who assisted him to bathe. Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 15 Those care plans reviewed in the sample, demonstrated appropriate input for all identified and emergent health care needs, including contact with hospital consultants and their staff, registration and at local GP surgeries, visits from and to district and psychiatric community nurses, tertiary health care from dentists, opticians, chiropodists, and audiologists, and professional advice and planning from dieticians, occupational therapists, and physiotherapists. Their psychiatric nurse was visiting one person, and during conversation she expressed positive comments about the way this particular service sought her input and advice at appropriate times, and ensured that any plans agreed were carried out for the benefit of the individual concerned. Grove Court DS0000004950.V348029.R02.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. This judgement has been made using available evidence including a visit to this service. People who use this service can be assisted to make and sustain complaints if they feel they have any, and are protected from abuse by the experience, knowledge, and commitment of staff who adhere to the agreed locally formulated policy on the protection of vulnerable adults. EVIDENCE: An appropriately formatted version of the complaints procedure was seen in the care plan of one resident, and another copy had been framed and was hanging in the entrance hall. A carer who the inspector engaged in a formal interview, stated that with some residents they would have to assist them to further any complaint they made, but others, they would be able to undertake this task perfectly adequately themselves. The agenda of the interview switched to the protection of vulnerable adults, where she displayed not only who her residents were at risk from (anybody) but also the various forms that abuse could take, and the procedure that she should follow, should she ever suspect that somebody living at Grove Court had been subjected to anything that was against their will. Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 29, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use this service live in premises that are suitable for purpose, and have sufficient individual room space that they can personalise as they choose, sufficient and appropriate bathrooms, toilets, and shared communal space, and enjoy a clean, warm, tidy, and odour free and environment. EVIDENCE: A cursory visual examination was made of the exterior of the home, and a more detailed examination of the interior of the home, without finding anything detrimental. The rooms of the people who use this service were comfortable and well furnished, with a very clear message about the personal choices of the individual residing there. Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 18 One lady, who invited the inspectors to review her room, had expressed her love of Manchester United by making this a shrine to the football club, with many treasured memorabilia items, including a photograph of George Best. Hers was one of the rooms that also benefits from a shower unit in the private ensuite. The inspector was also shown a former shared room that is now occupied by one person alone, and this too had ensuite shower provision, and like all other rooms visited had an appropriate call system for use in emergencies, radiators of the low temperature surface type, adequate storage space, furnishings, fixtures, and carpet in good condition, and appropriate restraints on the windows to prevent them from being a source of potential danger. Both of the bathrooms visited provided toilet facilities, and the unassisted bathroom which is on the first floor, had a shower that worked off the taps, and the thermometer to check water temperature was prominently situated beside it. The other bathroom had an Oxford Mermaid hoist to assist people with impaired mobility, and in this room there was a separate, walk in, shower unit. Both bathing facilities had appropriately tiled walls and impervious floor covering, and in the assisted bathroom there was a locked door leading to a secure storage area. Externally there was plenty of lawn space, with shrubs and mature trees, and a small number of flowerbeds. Sufficient garden furniture was provided, including seating just outside the back door, where some people who use this service exercise their right to smoke, when bad weather does not drive them inside to use the designated dining room. An unusual feature, was a gazebo that was both large enough for everybody to enjoy alfresco eating, and was provided with mosquito net style of sides, to exclude insects. The Registered Care Manager confirmed that there was an ongoing program of repairs and renewals, and particularly referred to a review of budget expenditure that she hoped would enable her to purchase a conservatory for the use of the smokers, as her application to Staffordshire county council for a portion of the special fund they had earmarked to assist residential homes meet the new legislation, had been turned down. Lounge and dining spaces were comfortably furnished with adequate provision for the number of people using this service, and no unpleasant odours were encountered in the home, reflecting that the needs of people living there to not currently require the use of the sluicing facilities on the two very substantial washers that are provided under a contract, and like the equally robust dryer, are located in the laundry. Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34,35, and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service benefit from both manager and staff being appropriately trained, qualified, competent, and experienced, to meet their known and emerging needs within the expressed aims and objectives of the home. EVIDENCE: Reference to the training matrix demonstrated that staff employed in this home undertake regular and periodic education to ensure that they have the competence and qualities required to meet the known and emerging needs of those people who use this service. In a formal interview, one of the shift leaders confirmed the commitment of these providers to the provision of good quality training, and the maintaining of a register of mandatory competencies to ensure that refresher courses were undertaken at the appropriate time. Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 20 When asked, she confirmed that the Registered Care Manager operated through a recruitment policy that was based on equal opportunities, and stated that all proper channels were followed during the process of her own promotion as they had been during her initial recruitment process some years previously. As a person in a senior position, she was able to corroborate the evidence found in staff records, that a proper advertising process was used, followed by the issuing of application forms, the gathering of written references, indication of suitability from the Criminal Records Bureau, including that this person did not appear on the PoVA list, and that new recruits were given proper induction, supervision, and opportunities for training and development. The dataset returned by these providers further showed that five of the 11 current permanent care staff already have NVQ level 2 or above, and that five further are at this time working towards obtaining that qualification. Currently there are only female carers in this home, but this was not identified as being an issue by any of the current people who use this service, from whom came many compliments and expressions of positive regard for the people who helped to look after them. Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use of this service have a manager who has just been approved as being qualified, competent, and sufficiently experienced to run the home and meet their needs and choices, in a way that protects their health, welfare and safety, and is, with the rest of the providers and staff, committed to canvassing their opinion on how this should best be done. EVIDENCE: The registration of a new care manager has been a requirement of the last report, and it is pleasing to confirm that the previous deputy has now been approved as a Fit Person to run this home. Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 22 She complied with all the criterias, having extensive experience of working in a managerial capacity in this home, and appropriate training and qualification in the needs of the people who use this particular service. The registered care manager confirmed that there was an annual development plan for the home, and that the views and needs of people to use the service was the primary determinant of this. She was able to show that a recent review of the budgetary processes of the home had identified several areas where savings could be made, and was most hopeful that the money saved would go towards funding the conservatory so necessary as a dedicated smoking area, because the majority of the people in the home are dedicated smokers. The inspector was able to review questionnaires that had been completed by the people who live in the home, giving their views on the way the service met their needs and choices. Reports of the monthly visit of the area manager were also available in the home, and these all included conversations that she has had with a representative number of the people who live there. During this inspection it was established that fire alarms were tested once a week as was the emergency lighting system and smoke detectors, and that the last fire evacuation drill had taken place on the 18th of July, including a full evacuation of everybody in the home. Other documents were seen to confirm the responsible attitude of these providers towards health and safety, including those for electrical testing, and servicing of equipment, medication administration records, menus, and a rota of the shift pattern of staff, and the matrix of their received and arranged training. Nothing seen in the documentation or during the tour of the environment, or heard in discussion with those people who use the service or those people who look after them, created any concerns about the health and safety measures in place to protect everybody in this home. Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 24 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 Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Birmingham Local Office 1st Floor Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Grove Court DS0000004950.V348029.R02.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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