Inspection on 19/07/06 for High Street (196)

This inspection was carried out on 19th July 2006.

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

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

Other inspections for this house

High Street (196) 15/07/08

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 196 High Street 196 High Street Rickmansworth Hertfordshire WD3 1BD Lead Inspector Louise Bushell Key Unannounced Inspection 19th July 2006 10:00 196 High Street DS0000067371.V305447.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 196 High Street DS0000067371.V305447.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. 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 196 High Street Address 196 High Street Rickmansworth Hertfordshire WD3 1BD 078990 46507 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) Caretech Community Service Limited Keith Parkes Care Home 12 Category(ies) of Learning disability (12), Mental disorder, registration, with number excluding learning disability or dementia (5), of places Physical disability (7) 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is the first inspection following registration in April 2006. Brief Description of the Service: 196 High Street is a 12-bedded home. It has been renovated from an original 22-bedded older person home. The home is in a residential area of a small bustling town and is located ideally to meet the needs of the service users, with amenities located within a short walking distance. The property benefits from being located within spacious grounds with landscape gardens designed to provide privacy for the service users and accessible flowerbeds, which will empower and enable service users to participate if desired. The 12-bedded home will operate as two separate units with the ground floor supporting 7 persons with associated physical disabilities and the first floor supporting 5 able bodied persons with associated behavioural issues that may challenge. All bedrooms have en-suite facilities with walk in shower areas. Suitable private lockable storage is provided in each room. Each bedroom exceeds the minimum measurements and presents extremely well with a number of bedrooms having exits straight into the private garden area. Each floor also has a lounge, dinning room, kitchen, and activity room, separate laundry with equipment as required to meet individual needs. All bathrooms and toilets are equipment to meet individual needs with aids and equipment. In addition to individual space and bathrooms there are additional bathing facilities that provide 2 bathrooms with ample space. Specialist Parker and Bagheera systems are provided including shower attachments and overhead tracking in the ground floor bathroom. There is a lift and staircase to the first floor with suitable fire exits throughout the building. 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection, following its registration on the 1st April 2006. This was an unannounced inspection aiming to inspect all key standards as a minimum. The inspection took place mid morning through until early afternoon. Time was directly spent with a number of service users, staff and the management of the home. 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. 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 6 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 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Service users are adequately supported through out the referral, admission and living at 196 the High Street. Information is provided to all in suitable means and formats. Contracts are in place so the rights of service users are protected. EVIDENCE: The home understands the importance of having sufficient information when choosing a Care Home. The home provides a Statement of Purpose that is specific to the individual home, and the resident group they care for. It clearly sets out the objectives and philosophy of the service supported by a Service user Guide. The guide details what the prospective individual can expect and gives a clear account of the specialist services provided, quality of the accommodation, qualifications and experience of staff, how to make a complaint, recent CSCI inspection findings and contains comments and experiences of residents living at the home. All residents are given a copy of the Guide. When requested the service can provide a copy of the SOP and guide in a format which will meet the capacity of the resident. Practice and information giving is informed by the services written procedures. 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 8 Admissions are not made to the home until a full needs assessment has been undertaken. For people whom are self funding and without a Care Management Assessment the assessment is always undertaken by a skilled and experienced member of staff. The assessment is conducted professionally and sensitively and involves the individual, and their family or representative, where appropriate. Where the assessment has been undertaken through care management arrangements the service insists on receiving a summary of the assessment and a copy of the care plan. A number of assessments were observed throughout the inspection and were seen to be completed with detail ensuring a holistic picture of care required was detailed within. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. The staff management team may consider the application together with other staff, where all information is shared, views, opinions, and comments are listened to and fully debated, before agreement is give for the admission. Prospective individuals are given the opportunity to spend time in the home. An individual member of staff is allocated to give them information and to help them understand how the home is organised and run and the facilities and services available. The allocated staff member will give them special attention, help them to feel comfortable in their surroundings, and enable them to ask any questions about life in the home. New residents are provided with a Statement of Terms and Conditions/Contract; this sets out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the individual. This is clear, jargon free, easy to understand and gives a very clear understanding of what residents can expect. The manager actively promotes opportunity for discussion and clarification. Terms and conditions are reviewed on a regular basis. All information collated as part of the referral, admission and assessment process to the home, was very well completed, precise and well organised. 196 High Street DS0000067371.V305447.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Service users needs are reflected adequately in their individual care plans. Service users are consulted with and are supported to take risks as part of an independent lifestyle. EVIDENCE: The service has a strong belief that it is essential to involve residents in the planning of care that affects their lifestyle and quality of life. Management and staff understand the importance of residents being supported to take control of their own lives, and to encourage and enable them to exercise their rights and make their own decisions and choices. Care plans are developed following person centred planning principles. Each resident has a plan that has been agreed with him or her. It is written in plain language, is easy to understand and considers all areas of the individual’s life including health; specialist treatments, personal and social care needs. 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 10 Staff have skills and ability to support and encourage residents to be involved in the ongoing development of their plan. Staff make the process interesting, using a variety of ways to enable residents to make a worthwhile contribution. A key worker system enables staff to establish special relationships and work on a one to one basis. The plan is reviewed regularly involving the resident and, where agreed, their families. It is updated and action taken to respond to any changes. It focuses on how residents will develop their skills and considers their future aspirations. All members of staff regard the plan as a working tool, they understand it, and support residents to achieve their desired outcomes. Staff are aware of current good practice and their practice promotes individuals to develop skills, including for some residents, independent living skills. Each care plan includes a comprehensive risk assessment. Management of risk takes into account the age, specialist needs of people who use the service, balanced with their aspirations for independence and choice. Where limitations are in place, the decisions have been made with the resident. There are procedures in place to ensure that residents are informed of their rights to confidentiality, and understand when staff may share information to ensure individuals are safeguarded. Individuals have access to advocacy services. The service is aware of current policy issues and good practice developments, and tries where possible to transfer this thinking into their daily work. The home ensures that residents are consulted on a regular basis to gather information about their satisfaction with how they are involved in both the development and review of the plan. 196 High Street DS0000067371.V305447.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service The service has a strong commitment to enabling residents to develop their skills, including social, emotional, communication, and independent living skills. Individuals are supported to identify their goals, and work to achieve them. Residents have the opportunity to develop and maintain important personal and family relationships, and are able to access information and specialist guidance. The practice of staff promotes individual rights and choice, but also considers protection of individuals, supporting people to make informed choices. Help with communication skills is given by the staff team, both within the service, and when accessing the community to enable residents to fully participate in daily living activities. 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 12 EVIDENCE: Residents are involved in meaningful daytime activities of their own choice and according to their individual interests and capability; they have been fully involved in the planning of their lifestyle and quality of life. Education and occupation opportunities are encouraged, supported and promoted. They can access and enjoy the opportunities available in their local community, e.g. using public transport, library services, the local pub, and local leisure facilities. The service is committed to the principles of inclusion and promotes, and fosters good relationships with neighbours and other members of the community. Currently the service users are accessing day care provisions provided by the staff team, whilst they are completing their transition to the home. It is anticipated that all service users will access day care service that are specifically designed to meet individual wishes and choices. Where appropriate residents are involved in the domestic routines of the home, they take responsibility for their own room, menu planning and cooking meals, making sure that they are able to enjoy the food they prefer and like. The menu is varied with a number of choices including a healthy option. It includes a variety of dishes that encourage individuals to try new and sometimes unfamiliar food. The meals are balanced and nutritional and cater for the varying cultural and dietary needs of the residents. Feedback was gained from three service users, which determined that they appeared happy in their new home. One service user was eating\lunch and appeared very relaxed and enjoying their lunch. A further service user stated that they really liked their new home, their room and that the staff are kind. 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 21 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Service users health care needs are fully supported and therefore all service users received a tailor made service suitable to meet individual needs. EVIDENCE: Specialist health, nursing and dietary requirements are clearly recorded in each resident’s plan; they give a comprehensive overview of their health needs and act as an indicator of change in health requirements. The Statement of Purpose details the specialist treatments the home can deliver and refers to the skills and ability of the staff group. Staff understand the key principles of giving personal support and are responsive to the varied and individual requirements of the residents. It is recognised that the delivery of personal care is highly individual and must be flexible, consistent and reliable. Attention is given to ensuring privacy and dignity when delivering personal care and staff are sensitive to changing needs of residents. When ever possible residents are able to have choice about who delivers their personal care. Where possible residents are supported and helped to be independent and responsible for their own personal hygiene and personal care. 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 14 Residents have access to health and remedial services, staff make sure that those residents who are fit and well enough are encouraged to be independent, have regular appointments and visit local health care services. The health care needs of residents unable to leave the home are managed by visits from local health care services. Personal aids and equipment are available and well maintained to support both resident and staff in daily living. The home works to an efficient medication policy supported by procedures and practice guidance. Staff is aware of and understand the guidance, and quality assurance systems confirm that practice reflects policy. High priority is given to maintaining and updating medication records. Staff follow robust systems to make sure that medication records are fully completed, contain required entries, and are signed by appropriate staff. Regular management checks are recorded to monitor compliance. Care plans contain clear information about the individual’s wishes when dying and after death. There are arrangements in place, which enable family and friends to stay and help with the care with the agreement of the resident. Staff support both the family and the homes’ other residents during the bereavement process. 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is up to date. The complaints procedure is widely distributed, and has a high profile within the service. There is a need for the home to ensure that the complaints procedure is in a suitable format to meet the needs of all service users. It is recommended that it is simplified into pictorial format. Advice was past to the deputy manager. EVIDENCE: The policies and procedures regarding protection of individuals are of a high quality and are regularly reviewed and updated. The service is clear when incidents need external input and who to refer the incident to. Training of staff in the area of protection is regularly arranged by the Home. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding when incidents should be reported. Staff spoken to displayed an adequate understanding of the adult protection procedure. Adult protection procedures are part of all staff’s mandatory training. The home has an open culture, which enables residents to express their views, and concerns in a safe and none blame environment. Residents and others associated with the service state that they are very satisfied with the service provision, feel very safe and well supported by an organisation that has their protection and safety as a priority. 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 30 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. All service users reside in a comfortable, homely and safe environment, empowering and supporting them individually. EVIDENCE: The home provides a physical environment that is appropriate to the specific needs of the residents who live there. The well-maintained environment provides specialist aids and equipment to meet the needs of the residents. The home is a very pleasant, safe place to live the bedrooms and communal rooms meet the NMS or are larger. The lay out and design of the home allows for small clusters of residents to live together in a non-institutional environment. Residents are encouraged to personalise their bedrooms. All the homes fixtures and fittings meet the needs of the individuals and can be changed if their needs change. All bedrooms have en-suite facilities with walk in shower areas. Where a service user has specified a bath this has been added to the private ensuite. Suitable private lockable storage is provided in each room. Each 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 17 bedroom exceeds the minimum measurements and presents extremely well with a number of bedrooms having exits straight into the private garden area. Each room has three double plug sockets, aerial points and phone lines can be added as required. Each floor also has a lounge, dinning room, kitchen, and activity room, separate laundry with equipment as required to meet individual needs. All bathrooms and toilets are equipment to meet individual needs with aids and equipment. In addition to individual space and bathrooms there are additional bathing facilities that provide 2 bathrooms with ample space. Specialist Parker and Bagheera systems are provided including shower attachments and overhead tracking in the ground floor bathroom. Electrical installations have been integrated into the design so as a need may arise on the first floor this is easily remedied and installed. Two mobile hoists are available and more will be purchased as required. All areas have been completed to a very high standard with a homely feel throughout the premises. All communal areas such as the kitchen, laundry and office are well equipped and meet all requited regulations and safety factors have been taken into account. There is a lift and staircase to the first floor with suitable fire exits throughout the building. Here is an additional front door entrance to the first floor should this be required. Suitable fire safety equipment is throughout and has been certificated; these are held on the registration file. Staffing facilities include suitable lockable facilities, toilet / wash room. All windows have been fitted with window restrictors and are suitable and safe to meet service users needs. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in privacy or in their own rooms. The management has a good infection control policy; they seek advice from external specialists, e.g. infection control, and encourage their own staff to work to the homes’ policy to reduce the risk of infection. 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Staff are suitably trained to meet the current needs of service users. The home’s recruitment and selection processes are adequate to ensure the safety and protection of service users. EVIDENCE: Residents have confidence in the staff that care for them. Rotas show well thought out and creative ways of making sure that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the residents. Staff members have the required experience and qualifications to work in the home. Staff are also completing the Ldaf qualification which is relative to their work. Managers encourage and enable this and recognise the benefits of a skilled, trained workforce. Accurate job descriptions and specifications clearly define the roles and responsibilities of staff. People who use the service report that staff working with them are very skilled in their role, and are consistently able to meet their needs. 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 19 The service ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving outcomes for residents. The service uses external providers to deliver this training if they have not got the appropriate skills within the organisation. The service has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. People who use the service are regularly involved in the recruitment process. Records were observed regarding the recruitment of staff and all records seen contained all required information and was extremely well organised. Staff recruited confirm that the service was clear about what was involved at all stages and was robust in the following of its procedure. Staff meetings take place regularly and records were observed. 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and service users can be assured that the care they receive is tailor made to suit their individual needs. Views of service users are taken into account when considering the running of the home. Health and safety is well managed ensuring that at all times safety is a priority for all. EVIDENCE: The Manager has the required qualifications and experience and is competent to run the home. He works to continuously improve services and provide an increased quality of life for residents. There is a strong ethos of being open and transparent in all areas of running of the home. The manager is person centred in their approach, and leads and supports a strong staff team who 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 21 have been recruited and trained to a high standard. The manager is aware of current developments both nationally and by CSCI and plans the service accordingly. The service has sound policies and procedures, which the manager effectively reviews and updates, in line with current thinking and practice. The manager is regarded highly by other professionals. Staff are positive in their approach to translate policy into practice. Efficient systems are in place to monitor staff adherence to policies and procedures during their practice. Management processes ensure that they receive feedback on their work. The home works to a clear health and safety policy, all staff are given a copy, and regular random checks take place to ensure they are working to it. The home has a good record of meeting relevant health and safety requirements and legislation. Records are of a good standard and are routinely completed. Residents are aware of safety arrangements and have confidence in the safe working practices of staff. The registered person has the skills and ability to deliver good business planning; effective financial controls and provides a quality assurance and monitoring processes. The home’s financial and business plan shows continuing growth supported by strong financial arrangements. The home has access to professional business and financial advice and has all the necessary insurance cover in place to enable it to fulfil any loss or legal liabilities. 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 22 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 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 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 3 X 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 23 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 YA22 Good Practice Recommendations It is recommended that the complaints procedure be displayed in a pictorial format to meet the needs of the current service users. 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 196 High Street DS0000067371.V305447.R01.S.doc Version 5.2 Page 25 - 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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