Inspection on 05/02/08 for Hamer Cottage

This inspection was carried out on 5th February 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hamer Cottage 10/10/06

Similar services:

Littledale Hall Therapeutic Community

Bennett House

Padgate House

Mary & Joseph

Westcliffe House

Richards House

Turning Point (Hoole Road)

Stanfield House

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

CARE HOME ADULTS 18-65 Hamer Cottage 107/109 Halifax Road Hamer Rochdale OL12 9BA Lead Inspector Val Bell Unannounced Inspection 5th February 2008 11:00 Hamer Cottage DS0000067103.V358976.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 Hamer Cottage DS0000067103.V358976.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. Hamer Cottage DS0000067103.V358976.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hamer Cottage Address 107/109 Halifax Road Hamer Rochdale OL12 9BA 01706 525325 01706 642012 info@hamercottage.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) Therapeutic Environments Limited Miss Helen Kate Morris Care Home 13 Category(ies) of Past or present alcohol dependence (13) registration, with number of places Hamer Cottage DS0000067103.V358976.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC To people of either gender whose primary care needs on admission to the home are within the following categories: Past or present alcohol dependence - Code A The maximum number of people who can be accommodated is 13. Date of last inspection 10th October 2006 Brief Description of the Service: Hamer Cottage provides care to 13 adults to enable them to develop skills to lead an alcohol free lifestyle and the home adheres to the dry rule. The project is housed in a listed building, which has been adapted to provide 13 single rooms. It is located approximately one mile from Rochdale centre, on the main road to Littleborough. It is close to shops, bus stops and a post office. As the house is a listed building, certain alterations cannot be made i.e. the front door is accessed via four steps (although handrails have been provided to each side) and a lift is not provided. The accommodation is therefore unsuitable for anyone with mobility or breathing difficulties. This information is included in the statement of purpose and service user guide. A garden and private car park are not provided, although a number of designated parking spaces are available to the rear of the building. The charge for this service is £395 per week. Hamer Cottage DS0000067103.V358976.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. This was a key inspection which included a site visit to the home. This visit was unannounced which means the manager was not informed beforehand that we were coming to inspect. During the visit we spent time talking to three people living in the home, a visiting care manager and a volunteer. Discussions were also held with the manager and two support workers. An Annual Quality Assurance Assessment (AQAA), which is a self-assessment document, had been completed and returned to us by the manager prior to this visit. It is our normal process to send surveys for the users of the service and staff to complete. The manager said that surveys had not been received from the Commission For Social Care Inspection (CSCI) prior to the visit and having checked our records we are not certain that these were sent out. Surveys were therefore left with the manager for distribution to staff and people living in the home. On receipt of the surveys we will use the information for the next time we undertake an inspection or annual service review. Relevant documents, systems and procedures were assessed and a tour of the home was undertaken. What the service does well: People spoken to during this inspection visit praised the quality of the staff and management in the home. They valued the fact that staff took time to listen to their views and consult them about decisions relating to the running of the home. People described staff as welcoming and efficient, particularly in relation to the admission process and ongoing support. This report highlights several areas of good practice (which has been sustained from the last inspection) in the way people are supported to exercise their rights to choice and self-determination and for person-centred practice in empowering people to work towards achieving their preferred lifestyles. People using the service are encouraged to develop new skills, interests and hobbies and to take responsibility for their own recovery. House rules and any restrictions to choice and freedom, necessary to the therapeutic programme in place, are explained in full prior to admission. Good practice examples have also been highlighted in the way that the service engages with relatives and friends to ensure that people develop support networks that strengthen and sustain their move to independent lifestyles. A volunteer who was previously accommodated in the home said, ‘Staff helped me to overcome my alcohol problems and now I want to put something back Hamer Cottage DS0000067103.V358976.R02.S.doc Version 5.2 Page 6 into the service by offering support to the current residents.’ He added that the manager is efficient at running the home. The service received a commendation for exceeding the National Minimum Standards in relation to the way staff are supported to develop their focus on meeting individuals’ needs in a person-centred way. The homes environment is clean and well maintained. The people accommodated take responsibility for maintaining good standards in this area under the supervision of staff. A person recently admitted said that he had chosen this home as cleanliness was very important to him. What has improved since the last inspection? What they could do better: The system in place for secondary dispensing of medication into plastic bags for administration to people accommodated in the home had been highlighted as needing further consideration during an inspection in February 2006. This issue had been discussed between the manager and representatives of the Primary Care Trust and the Commission around the time of the last inspection in October 2006. It was noted that the manager had consulted the local pharmacist about providing a ‘safer and more effective way of holding and dispensing drugs.’ At this inspection that staff were continuing to secondary dispense medication into plastic bags. There was no evidence to suggest that anyone using this service had suffered any harm although this method of Hamer Cottage DS0000067103.V358976.R02.S.doc Version 5.2 Page 7 medication administration potentially places the welfare of people at risk. It is required that a system of medication that safeguards the health and welfare of people using this service is implemented as a priority. 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. Hamer Cottage DS0000067103.V358976.R02.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 Hamer Cottage DS0000067103.V358976.R02.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 Quality in this outcome area is excellent. Thorough in-house assessments by trained staff ensure that the needs of people admitted to the home are identified and written down. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The thorough assessment process outlined in the inspection report of October 2006 continues to be in place. Care records belonging to three people accommodated in the home were examined for evidence that they had received assessments of their needs prior to admission. Trained staff working in the home had undertaken comprehensive assessments to determine if the service would be suitable to meet each individual’s needs. The members of staff and the person being assessed had signed the assessment forms to agree the contents. Following the assessments, acceptance letters had been sent to the three people and their care managers. One of the care records did not contain a care manager assessment of need (core assessment). The practice of not always receiving a care manager’s assessment prior to admission had been highlighted in the October 2006 Hamer Cottage DS0000067103.V358976.R02.S.doc Version 5.2 Page 10 inspection. Written information provided by the manager prior to the inspection said, ‘Currently it is rare that care managers fax through a core assessment prior to the service user visiting our premises so we are reliant soley on the information provided to us by the service user on assessment. We aim to reach a target of receiving core assessments for 75 of service users coming for assessment with us.’ The manager acknowledged that this information should be obtained and said they strived to obtain it. Following the last inspection, she introduced as part of the assessment process an added question appertaining to the provision of the care manager assessment. Staff are aware they need to ask for this information. We saw evidence of this on the file we looked at. Hamer Cottage DS0000067103.V358976.R02.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 and 9 Quality in this outcome area is good. People admitted to the home receive the right level of support to develop the skills necessary for living independently. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care records belonging to three people living in the home, contained clear details of the support that was needed to meet the assessed needs of each individual. The self-assessment document completed by the manager stated that care plan formats were being reviewed as part of the home’s continuous development programme, and these have now been done. Staff and people using the service had been consulted on how care plans could be improved to provide better consistency. People using this service are encouraged to take responsibility for their own recovery while receiving support to enable them to develop self-confidence and life skills in preparation for independent living. A person due to move out Hamer Cottage DS0000067103.V358976.R02.S.doc Version 5.2 Page 12 of the home said, “I am leaving on Monday and staff have prepared me well for this move. It’s been hard work but the staff have been great. Ten out of ten. They ask your opinion about everything that goes on in the home.” Another person who had recently been admitted confirmed that restrictions on choice and freedom had been discussed, agreed with him and written down. He said he had been allocated a key worker who would discuss his progress with him regularly and assigned a ‘be-friender’ who was another person who had lived in the home for some time. He explained that this person would assist him to become familiar with the home and finding his way round the local community. He added that everyone had made him feel welcome. The support that people receive following their admission to the home is considered to be an example of good practice. Risks identified during the assessment process had been assessed and written guidance provided on the support needed to keep people safe. The last inspection report highlighted many of the processes in place to support people in their recovery such as the “spider” outcome charts. We saw evidence that these continue to be used, and are completed in conjunction with the service user at differing levels of their recovery. Six weeks reviews remain a part of the care planning process, and care managers are kept updated on their clients progress in the service. Hamer Cottage DS0000067103.V358976.R02.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, 16 and 17 Quality in this outcome area is good. People living in this home are empowered to develop the personal skills and knowledge necessary to achieve their preferred lifestyles. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home attend daily group therapy sessions and one-to-one sessions with their nominated key worker. These sessions are compulsory and are designed to enable personal growth. They cover such areas as emotional development, social skills training, alcohol awareness, faith groups and life story groups etc. Separate groups are provided for men and women. People living in the home have the option to run a group session when they have developed sufficient self-confidence. Links have been forged with a voluntary organisation in Rochdale. One person living in the home is currently doing voluntary work and a second is awaiting a Hamer Cottage DS0000067103.V358976.R02.S.doc Version 5.2 Page 14 suitable placement. Information regarding educational activities and community resources is on display and people are encouraged through the care plan process to develop new interests and hobbies. Care plans provided evidence of this by recording each person’s interests and preferred future lifestyles. Three people were asked about what they do during the day. They agreed that apart from attending the group therapy and one-to-one sessions they had free choice in how they wanted to spend their time. One person was busy preparing for a visit from a relative and a second person had planned to go out in the afternoon. The third person had discussed going out with his befriender to become familiar at finding his was round the local community. This provided evidence that people were being supported to exercise choice and self-determination in a person-centred way. An optional activities group is available to encourage people to develop new interests and hobbies and care plans had been reviewed every six weeks to ensure that the activities provided were relevant to individuals’ needs. Relatives are encouraged to become involved in their family member’s rehabilitation through invitations to monthly meetings. Training is also offered to relatives to enable them to learn more about the rehabilitation process. This provided further evidence of good practice in developing support networks for people living in the home. People living in the home prepare their own breakfast and lunch and take turns to cook the evening meal for everyone in residence. Mealtimes are flexible according to individual choice. People also choose their own menus and prepare weekly food shopping lists. One person said, ‘There’s always plenty of food in. Sometimes we’re spoilt for choice.’ It was pleasing to note that the home achieved the Bronze Award from Rochdale Environmental Health Department in August 2007. This was awarded for achieving good practice in customer involvement in menu preparation, enabling choice, healthy and balanced diets and for good hygiene practice. Hamer Cottage DS0000067103.V358976.R02.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 and 20 Quality in this outcome area is good. People using this service receive the support they need to take responsibility for their healthcare needs, although the current system of medication potentially places their welfare at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two of the three care plans examined contained evidence that people receive the right level of support to manage their own healthcare needs in preparation for an independent lifestyle. People are encouraged to attend appointments on their own or with their befriender (fellow resident), although staff support is available if needed or requested. Information in care plans and conversations with two people using this service confirmed that support is provided in a person-centred way. During the inspection we noted that a member of staff had applied first aid to a person following a minor fall. A member of staff had completed an accident form stating that the abrasion had been cleaned up and a dressing applied to the injury. The manager needs to be mindful when staff apply first aid that it Hamer Cottage DS0000067103.V358976.R02.S.doc Version 5.2 Page 16 is appropriate and if medical intervention is considered necessary the person should be referred to the relevant health professional. People admitted to the home are encouraged to take responsibility for administering their own medication if they are assessed as safe to do so. People who needed support with this were having measured doses of medication placed by staff into three plastic bags per day for selfadministration at the prescribed times. As the home was not staffed at weekends, some people were being given nine plastic bags of medication on Fridays. This method of secondary dispensing medication from pharmacy packaging into alternative containers is unsafe and potentially places people at risk. This practice has been in place for some time at Hamer Cottage, and has been highlighted in previous inspections with a requirement made in the February 2006 inspection. A conversation with the manager revealed that the medication system was discussed with representatives from the Primary Care Trust and the Commission for Social Care Inspection around the time of the inspection in October 2006. Written evidence provided by the manager showed that there had been repeated attempts made to discuss the way forward with the local pharmacist and general practitioner up to May 2007 although a suitable safe alternative could not be agreed. There was no evidence to suggest that the health and safety of people using this service had been compromised. However, it is required that a safe system of administering medication be implemented as a priority. Hamer Cottage DS0000067103.V358976.R02.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 and 23 Quality in this outcome area is good. People using this service are listened to and procedures are in place to safeguard their welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A policy and procedure for dealing with complaints within prescribed time limits had been implemented in the home. People were given written information about this at the time of their admission and the procedure for complaints had been posted on a notice board in the home. No complaints had been received about this service during the period since the last inspection in 2006. Three people spoken to said that they knew how to express concerns or complaints. One person said, ‘I’ve been here for about eight months and I’ve had nothing to complain about. Staff always make time to listen to you if you have any worries.’ Rochdale’s inter-agency policy and procedures on safeguarding people from harm had been implemented in the home. Three members of staff confirmed that they had received training in what action they must take if abuse is alleged or suspected. The home’s training matrix provided evidence of training completed by individual members of staff. Hamer Cottage DS0000067103.V358976.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. People using this service are provided with a clean, homely and well-maintained living environment that meets their assessed needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Hamer Cottage is a listed building and this means that certain adaptations are not permitted. For example, there is no disabled access to the home. This information is included in the written information provided to people enquiring about this service. A tour of the home was undertaken to assess cleanliness, hygiene and health and safety and one of the people accommodated showed us her bedroom. People living in the home are responsible for daily housework tasks under the supervision of the staff team and the environment is deep cleaned once a Hamer Cottage DS0000067103.V358976.R02.S.doc Version 5.2 Page 19 month. Communal and private areas seen were found to be clean and hygienic and no health and safety issues were found. Two people confirmed that they had been encouraged to bring possessions with them on admission to personalise their bedrooms and reflect their interests. The three people spoken to said that they were satisfied with the facilities provided. The home had a warm and welcoming atmosphere. Equipment used in the home had been subject to regular servicing and maintenance and a programme of redecoration, replacement and renewal was in place. Hamer Cottage DS0000067103.V358976.R02.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, 34, 35 and 36 Quality in this outcome area is excellent. Staff receive support and guidance in excess of the National Minimum Standards and this ensures that people admitted to the home receive a service designed to meet their needs in a person-centred way. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three staff files examined contained evidence of Criminal Record Bureau (CRB) disclosures and two written references. The manager said that newly appointed staff did not work unsupervised until satisfactory CRB certificates had been received. Newly appointed staff underwent a 3-month probationary period after which their performance was reviewed and their development needs assessed. During the probationary period staff undertook a comprehensive induction programme and mandatory health and safety training. The manager explained that moving and handling training was not provided, as staff were not required to undertake any lifting tasks in the course of their work. The support staff employed are trained counsellors. Hamer Cottage DS0000067103.V358976.R02.S.doc Version 5.2 Page 21 Staff received 6-weekly supervision with their line manager and monthly team supervision was provided for therapeutic staff. The staff team had fortnightly meetings to ensure that vital information was passed on and to review systems and procedures in place at the home. The outcome of these meetings had been written down. In the self-assessment document provided, the manager wrote, ‘Team working is high on our agenda as we recognise the importance of good working relationships in providing a consistently exceptional service.’ Two people living in the home and a volunteer praised the quality of support provided by the staff. One person said, ‘the staff go above and beyond the call of duty. I wouldn’t be where I was now if it wasn’t for them. I couldn’t have asked for more.’ It was evident from observations of interactions during the inspection visit that staff had formed relationships with people using the service based on mutual respect and trust. This provides evidence that the National Minimum Standards have been exceeded in the area of staff development. A commendation was made for best practice in supporting staff to develop the knowledge and skills needed to provide a person-centred service. Three staff were working to achieve a National Vocational Qualification in care at level 4 and individual staff receive in excess of 5 days paid training per year. This was confirmed in conversation with two members of staff during the inspection visit. Hamer Cottage DS0000067103.V358976.R02.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 and 42 Quality in this outcome area is excellent. The home is managed in the best interests of the people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is well qualified. She has a Business Studies Diploma, a BA Hons in European Marketing, a Diploma in Psychology, a Level 3 Diploma in Counselling, an NVQ4 in care and holds the Registered Manager’s Award. She is currently studying for a Masters degree in Psychology. People living in the home and staff spoken to said that the manager provided good support systems within the home and that it was a good place to live and work. A care manager visiting her client during the inspection visit said, ‘I Hamer Cottage DS0000067103.V358976.R02.S.doc Version 5.2 Page 23 have found the staff to be very professional and responsive to requests for information. Communication has been good and my client is satisfied with the service he receives.’ This service has achieved the Investors in People Award and this is due to be re-assessed in November 2008. A comprehensive quality assurance monitoring system is in place based on the views of people using the service. Information gathered from surveys, business meetings and a variety of feedback sessions is used to measure how well the service is performing in meeting its aims and objectives. Three people using this service said that their views are taken seriously and suggestions for improvement are put into place following consultation. One person said, ‘Staff take time to listen to what you have to say. No changes are made without us being asked first.’ This type of feedback obtained from service users was in place on the October 2006 inspection and shows the commitment from the manager and staff to sustaining good practice in seeking the views of service users, their relatives, care managers, and staff and ensuring such views influence how the service is delivered. A sample of health and safety records was found to be accurate and up to date. No health and safety shortfalls were found during the inspection visit. Hamer Cottage DS0000067103.V358976.R02.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 4 33 X 34 3 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 4 X 4 X X 3 X Hamer Cottage DS0000067103.V358976.R02.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. 1. Standard YA20 Regulation 13 (2) Requirement A suitable and safe system of medication must be implemented to ensure that the health and welfare of people accommodated in the home is not placed at risk. Timescale for action 05/03/08 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 Hamer Cottage DS0000067103.V358976.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Hamer Cottage DS0000067103.V358976.R02.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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