Inspection on 24/10/07 for Heathercroft

This inspection was carried out on 24th October 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

Heathercroft 28/09/06

Heathercroft 20/05/05

Heathercroft 26/01/05

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Heathercroft 18 Wolverton Gardens Horley Surrey RH6 7LX Lead Inspector Suzanne Magnier Unannounced Inspection 24th October 2007 10:30 Heathercroft DS0000059971.V348236.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 Heathercroft DS0000059971.V348236.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. Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heathercroft Address 18 Wolverton Gardens Horley Surrey RH6 7LX 01293 774813 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) wolverton@prospectha.org.uk Prospect Housing and Support Services Mr Louis Serge Begue Care Home 5 Category(ies) of Learning disability (0) registration, with number of places Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 5. Date of last inspection 28th September 2006 Brief Description of the Service: Heathercroft is a care home providing personal care and accommodation for 5 people with moderate to severe learning disabilities. The home was opened in 1997 and is owned and maintained by Prospect Housing and Support Services and is located on the outskirts of Horley, near Gatwick. The bungalow accommodation provides all ground floor facilities including an office, lounge and dining area, kitchen, bathrooms, toilets, laundry area and five single bedrooms. The home has a garden, which is private, secure and accessible for residents. Limited private parking is available. The home has a vehicle and residents are supported to access the shops and other amenities. The range of fees charged by the home are is £1521.77 per week. Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the care home was an unannounced ‘Key Inspection’. Some additional standards were assessed and have been included within the report. Ms S Magnier Regulation Inspector carried out the inspection and the assistant director and senior support worker represented the service. For the purpose of the report the individuals using the service are referred to residents or people living in the home. The inspector arrived at the service at 10.30 and was in the home for five hours. It was a thorough look at how well the home is doing. It took into account detailed information provided by the assistant director, and any information that CSCI has received about the service since the last inspection. Several residents do not use formal speech to communicate and the inspector spent time being with individuals during the inspection and observed their interactions and body language as a means of communication. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Documents sampled during the inspection included the homes Service User Guide and Statement of Purpose, care/person centred plans, daily records and risk assessments, medication procedures, staff training records, health and safety records and a tour of the premises. Following a previous key inspection in September 2006 the service has met all the requirements made. The home has submitted the Annual Quality Assurance Assessment (AQAA) prior to the inspection. The document was noted to be incomplete yet some details have been added to the report. No comment cards, sent by the Commission have been returned. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. From the evidence seen by the inspector and comments received, the inspector considers that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. The inspector would like to thank the people living in the home, the staff and the assistant director for their time, assistance and hospitality during this inspection. Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 6 What the service does well: 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. Heathercroft DS0000059971.V348236.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 Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for a care needs assessment for individuals to ensure that their needs are assessed and identified before admission to the home. Prospective people have sufficient information to make an informed choice if they would like to live in the home which include trial periods of stay in the home if they choose and terms and conditions of stay in the home. EVIDENCE: The inspector sampled the homes Statement of Purpose and Service User Guide and evidenced that appropriate information regarding the services of the home were clearly documented to inform prospective residents or their representatives about the services provided by the home. The assistant director discussed ways in which the Statement of Purpose and Service User Guide could be available to individuals with diverse needs for example sensory and memory impairment in order that all individuals would have access to information in a format suitable to their needs. The assistant director made some minor amendments to the Service User Guide and The Statement of Purpose during the inspection. Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 9 The inspector was advised that prospective residents are admitted to the home on the basis of a full assessment of needs undertaken by professionals competent to do so. Whilst sampling a resident’s care plan the inspector confirmed the home has a policy on needs assessment and a pre-assessment checklist that covered personal care, health needs and social support. The assistant director had completed the pre admission assessment and a variety of associated documents from other health care professionals regarding the care and support needs for the individual. The ethnicity and diversity of the individual was reflected in the assessment for admission and it was evident during the inspection that the home was aware of the needs of all individuals from differing cultures and faiths. The assistant director advised the inspector that the home assists residents to move to the home at their own pace which includes visits, sharing meal times and ensuring the compatibility of the persons needs and individuality with regard to their home companions. Whilst sampling resident’s files it was noted that each person had a copy of their terms and conditions of stay in the home. Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has robust care plans and risk assessments. The documents were well recorded to ensure that the residents changing needs, safety and wellbeing were being met. Some improvement to the documentation has been recommended. People make decisions regarding their life and have some participation in the running of their home. EVIDENCE: The inspector sampled two care plans. Both of the care plans were noted to be well written and contained documentation to demonstrate the care needs of the individual. Agreed working guidelines were in place to offer individuals a consistent and supportive plan of care. The care plans detailed the individuals preferred choice of name, their relatives and friends contact details, the individuals hobbies, likes and dislikes, how the individual communicates, what objects, places or people are significant in their Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 11 lives, their personal history’s and what support and assistance they would like and need from staff. It was evident that the home were making efforts to move to a more person centred approach with regard to the care plans and the inspector sampled one person centred plan which was easier to understand and offered more clarity regarding the individual and their lifestyle and needs. It is recommended that the care plans continue to be further improved and developed to include a more person centred approach to reflect the individuality of the person receiving care and support in the home. The inspector observed staff openly engaging with individuals who did not use formal speech to communicate and demonstrated when questioned an underlying knowledge of the individual and the way they communicated. This enabled the individuals to put their views across, make their own decisions and be understood by the people around them. Staff members spoken with during the course of the inspection demonstrated an understanding of the way individuals communicate through behaviours that may ‘test’ the service. The staff were aware of the environmental factors that may upset or distress an individual and were supportive and acted promptly to diffuse any behaviour, which could escalate. Whilst sampling the care plans the inspector noted that there were agreed working practices and well documented risk assessments available for all staff to follow when supporting residents with their personal care, distress, mobility, support with meals, support during and after seizures, and when out and about away from home and for any hazard identified in the individuals daily living. Staff had signed the risk assessments and there was evidence that the assessments had been reviewed at appropriate intervals. The daily records written by staff were well written and documented clearly the support and care the person had received and how they had spent their day. Evidence of reviews of care plans was sampled in order to ensure that the changing needs or support the individual requires is documented and the individual’s needs are met. Whilst sampling some documents the inspector observed a documented goal plan for one individual making a cup of coffee. The goal plan was dated 2005 and was discussed with the senior care worker and the assistant director. It was apparent that there was not clear evidence of individual’s achievement of this goal or other aspirations being recorded. A recommendation has been made that all individuals goals and aspirations are updated, clearly recorded, audited, and achievements noted. Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements are good ensuring residents participate in valued and fulfilling activities and are part of their local community. Residents are supported to maintain links with family and friends. Resident’s rights are respected and responsibilities recognised in their daily lives. Meals at the home are good and offer variety, choice and healthy eating options. EVIDENCE: The inspector discussed the activities provided by the home with the senior support worker who advised that residents take part in valued and fulfilling activities. An activities plan was sampled and confirmed that residents have individual activity programmes and activity logs. It was noted that residents were involved in hack riding, going to the cinema, having meals out, going for walks, swimming, music sessions and attending Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 13 day centres. On the day of inspection an aroma therapist was at the home offering therapy to several individuals and also a representative from a local day service was supporting people on an individual basis in their local community. Further evidence confirmed the home values equality and diversity and residents would have access to the local church to satisfy their religious needs if they chose to attend. The senior support worker advised that the home have a visitor’s policy and family and friends are welcomed at the home. Staff have training during their induction regarding acknowledging the residents rights to privacy and dignity. It was observed that staff addressed residents by their preferred names and also terms of endearment to promote trusting relationships. Staff were observed to knock on residents doors before entering bedrooms and bathrooms. It was noted that the toilets and bathrooms did not have ‘vacant and engaged’ signs and it has been recommended that signs indicating the use of the facilities be displayed on the bathroom/toilet doors to help promote peoples rights to dignity and privacy. The assistant director advised that the home promotes gender specific care and it was observed that support in offering personal care was undertaken in a respectful manner. The inspector observed that one resident was sitting on their lounge sofa on a Kylie sheet and this was brought to the assistant directors attention who recognised that this did not afford the resident dignity and respect. The staff took immediate action to remove the Kylie and place it under the cushion covering. The home has restricted access to the kitchen and this practice was discussed with the assistant director who advised the inspector of the reasoning behind the restriction. The homes kitchen risk assessment was sampled and some minor amendments made regarding the use of the restriction with regard to the safety and wellbeing of some residents in the home. Staff confirmed that they would support and supervise some residents in the kitchen a one to one basis. The inspector sampled the homes written menus and noted variety and choice with healthy eating options. The file sampled contained various photographs of meals that the staff member advised are shown to residents to assist them in choosing what they might like to eat. It was noted that the photographs were of a poor quality and it was agreed with the assistant director that an improvement in the presentation of the documents needed to be made. On the day of the inspection the residents had freshly prepared omelettes for lunch and a dessert. The mealtime was relaxed and unhurried and staff were available to support residents if they needed assistance. Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 14 There was evidence to support that some residents were being encouraged to eat healthy meals and reduce their body weight however records sampled were not current. The records were discussed with the assistant director and the senior staff member who advised that the documents were not currently in use and needed to be archived. Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for personal support are good ensuring residents receive personal support in the way they require and prefer. The systems for healthcare are good ensuring residents physical and emotional needs are met. The management of medication is good and safeguard the welfare of residents. EVIDENCE: Whilst sampling the residents care plans the inspector noted that the individual care plans reflected flexible personal support and included morning and evening routines, night support and moving and handling guidelines. The home has arrangements for meeting the healthcare needs of residents and this was demonstrated through sampling care plans and daily notes, which included details of attended appointments with health care professionals. Records indicated that residents were registered with a local GP (General Practitioner) with input from district nurses, chiropodist, dentist and optician and continence advisors to promote health and hygiene. Referrals to other relevant professionals are made through the GP as appropriate. Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 16 The home has a medication policy and a service level agreement with a local chemist to supply medications to the home. The inspector sampled medication record sheets, which were dated and signed by staff and contained evidence of medications received by and disposed of by the home to prevent mishandling of medications. Observations confirmed the home had adequate storage of medications and staff have accredited medication training. The home has clear guidance regarding the use of PRN (as necessary medications) and the assistant director and staff members confirmed that this form of medication is only administered with the authority of the service manager or on-call manager. The home have a list of staff competent to administer medications with specimen signatures for information and homely remedies were listed and approved by a doctor to safeguard the welfare of residents. Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. Residents are encouraged to express their concerns and have access to a complaints procedure and are protected from abuse and have their rights protected. EVIDENCE: The home has a clear complaints procedure, which has also been adapted in differing formats for residents. The AQAA and the assistant director confirmed that no complaints had been received since the previous inspection. Whilst sampling the complaints log the inspector noted that there was a detailed clear chronology of events for example dates and details of correspondence and outcomes regarding complaints previously received by the home. The AQAA and the assistant director confirmed that there had been no safeguarding referrals under the safeguarding adults procedures. The inspector noted that the home has a whistle blowing policy and procedure, which is available to staff in order to safeguard people in their care. The inspector noted that the home did not have the local authorities multi agency procedures for safeguarding adults available at the time of the inspection. The assistant director confirmed that the home did have a copy and it would be located as a matter of urgency. Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 18 Staff and the assistant director spoken with during the inspection demonstrated an understanding of the procedures for safeguarding adults and training records detailed that staff receive safeguarding adults awareness training. Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises are good enabling residents to live in a homely and comfortable environment. The arrangements for hygiene are good ensuring the home is clean and hygienic for residents. EVIDENCE: The home’s premises are suitable for its stated purpose and are in keeping with the local community. On the day of the inspection the home was clean, well ventilated and free from offensive odours. The wear and tear of the soft furnishings was discussed with the assistant director and observations confirmed the home has a good standard of décor with good quality furniture and fittings. The communal areas, bathing and toilet facilities and the grounds were all well maintained and accessible to all the residents in their home. The home had a policy on infection control and adequate laundry facilities with an industrial washing machine and domestic dryer. Observations confirmed Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 20 hand washing facilities were prominently sited in the kitchen and laundry area and staff practiced infection control measures by washing their hands regularly to prevent the spread of infection. Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 21 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to provide 24hour support to residents. The home has a robust system for the induction, training development and recruitment of staff to ensure that individuals needs are met appropriately and safely. EVIDENCE: The home currently employs nine care staff. On the day of the inspection there were three care staff on duty. All staff were observed as skilled in supporting the people in their care and were knowledgeable regarding the specific needs of individuals to ensure their safety, well being and offer reassurance. The home has a recruitment and selection policy, which incorporates equal opportunities. The assistant director advised the inspector that no staff had been employed since the previous inspection and therefore staff recruitment files were not sampled. Files sampled during the previous inspection evidenced that the home undertake appropriate vetting procedures in order to safeguard residents at the home. The assistant director detailed the recruitment process, for example a completed application form, face- to -face Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 22 interviews, references, CRB clearances and job descriptions and advised that the home were currently advertising to the homes one vacant staff position. The inspector noted that five staff have achieved their National Vocational Qualification (NVQ) qualification and two staff have applied to undertake the course. The assistant director advised that Prospect Housing is an assessment centre and have a policy on induction and a structured staff induction to reflect Skills for Care Common Induction Standards and the revised Learning Disability Award Framework (LDAF). The inspector noted training and development are linked to the home’s service aims and a rolling programme of training was available to all staff. Records indicated that staff had received induction, mandatory training and specialist training foe example epilepsy, person centred planning, management courses, supervision and appraisal and information regarding the mental capacity act. Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 23 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, 40, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for the day to day management of the home are good ensuring residents benefit from a well run home. The systems for quality assurance are good ensuring residents participate in the review of the home. The arrangements for health and safety are robust to ensure safe working practices. EVIDENCE: The home has appointed a manager who has registered with the CSCI as the registered manager to the home. The assistant director advised that the manager has a job description and is aware of their role and responsibilities. It was acknowledged with staff that the home has undergone managerial change in the past and that the appointment of the new manager would help to consolidate change and assist the service as a whole. Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 24 The pace of the home was designed to meet the needs of all the residents and it was evident through talking with staff that the manager had good knowledge about managing the care home and had the skills and experience to ensure the safety and well being of all persons in the home. The home has a policy on quality assurance with regular monitoring visits. The inspector noted the home used questionnaires to survey all persons associated with the home including residents, their family and friends and healthcare professionals to obtain feedback about the home. Files sampled contained the last quality assurance records dated 2006 yet the assistant director advised that quality assurance had been undertaken in 2007 with the outcomes being currently collated by Prospect Housing. The inspector sampled the financial records and safe keeping of resident’s funds and noted that all transactions were accurate and well recorded to protect residents from financial harm. The home has a policy on health and safety and staff have training in health and safety, fire safety, food hygiene, first aid and manual handling. Further evidence confirmed the home had a policy on COSHH (Control of Substances Hazardous to Health) with products appropriately stored in a locked cupboard. Observations indicated the home had health and safety information displayed in the home. Records and observations confirmed that the home has fire equipment, emergency lighting and emergency call systems. The kitchen appeared clean and hygienic with food safety procedures in place to safeguard the welfare of residents. Following discussions with the assistant director and senior staff member it has been recommended that the system for recording food, fridge and freezer temperatures is revised as the home is currently using two systems which could lead to inaccurate recording. The homes records indicate that health and safety checks are undertaken and infection control measures in place which also include hand washing facilities throughout the home. The accident and incident book was sampled and evidenced that the home have reported the the CSCI under Regulation 37 notifications events that affect the well being and welfare of residents. Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 25 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 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 X 3 X Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 26 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 YA6 Good Practice Recommendations 2 YA6 3 YA16 Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Heathercroft DS0000059971.V348236.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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