Inspection on 11/09/07 for Highbury House

This inspection was carried out on 11th September 2007.

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

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

Other inspections for this house

Highbury House 12/10/06

Highbury House 07/02/06

Highbury House 19/05/05

Highbury House 20/10/04

Highbury House 04/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Highbury House 207 Outland Road Peverell Plymouth Devon PL2 3PF Lead Inspector Kim Fowler Unannounced Inspection 11th September 2007 10:00 Highbury House DS0000003519.V345261.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 Highbury House DS0000003519.V345261.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. Highbury House DS0000003519.V345261.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highbury House Address 207 Outland Road Peverell Plymouth Devon PL2 3PF 01752 753710 01752 796299 admin@plymouthhighburytrust.org.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) Plymouth Highbury Trust Mr Ian Philip Oliver Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Highbury House DS0000003519.V345261.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Age 18-65 Three named Service Users over the age of 65 Service Users with a Learning Disability, some of whom may also have a Physical Disability. 12th October 2006 Date of last inspection Brief Description of the Service: Highbury House is a care home providing personal care and accommodation for nine people with learning disabilities. It is owned by the Plymouth Highbury Trust, which is a voluntary sector organisation, and affiliated to the Royal Mencap Society. This home is located in the residential area of Peverell, close to shops, pubs, the post office and other amenities. The home was opened in 2000 and is situated on the 1st floor of a building on the site of the Plymouth Mencap Society, where there is also another care home and a day centre owned and managed by the Society. There are stairs and a shaft lift available. The ground floor of the building is used by the Local Authority to provide a day service for adults with learning disabilities and there is a separate entrance. All the homes bedrooms are single and none of them have en suite facilities. There are separate lounge and dining rooms and the home has a call bell system throughout. The home has an attractive patio and garden accessible to all the service users, shared with the other facilities on the site. The home is staffed 24 hours a day; there are 2 care staff sleeping in at night. Highbury House DS0000003519.V345261.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 1 day and started at 10:00am and finished at 3.40pm. The registered manager Mr Ian Oliver was available throughout the inspection. The inspector made a tour of the building and spoke to all of the people living at the home. Documentation relating to the care planning process and the management of the home were examined. All the people living at the home and two relatives were spoken with and any comments are discussed in the relevant section of the report. What the service does well: What has improved since the last inspection? What they could do better: The home needs to update the Quality Assurance systems as stated in the home AQAA returned to the Commission. No Requirements or Recommendations have been made in this report. Highbury House DS0000003519.V345261.R01.S.doc Version 5.2 Page 6 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. Highbury House DS0000003519.V345261.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 Highbury House DS0000003519.V345261.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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective new admissions can be assured that the home will completed a pre-admission assessment to assist staff to meet their individual needs. EVIDENCE: Highbury House has had no new admission for 6 years. However from discussion with the Registered Manager, Mr Ian Oliver, he is fully aware of the home pre-admission procedure. This procedure is based on person centred planning to ensure any prospective new admissions are suitable for admission to the home. The admission process also includes taking a full history and assessment of needs. This would ensure that the care needs of any person moving into the home could be met. Pre-admission information would also provide information for individual care plans. This information would be important so prospective admissions are assured that not only can their health care needs but also their physical needs are managed and met by the home. Highbury House DS0000003519.V345261.R01.S.doc Version 5.2 Page 9 The homes AQAA states that, “Due to this (no recent admissions) I am aware that our policy and procedure for this task is not perhaps as clear as it could be” and goes onto state that the manager will be reviewing this. Highbury House DS0000003519.V345261.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 excellent. This judgement has been made using available evidence including a visit to this service. People are encouraged and supported to make daily decisions about their own lives to maintain their independence. EVIDENCE: The files for six people living at the home were examined. All six files examined held individual care plans in place and the details held on these files are needed by staff to met individual needs. These care plans show a breakdown of the services and facilities provided by the home as well as current needs, specialist input and guidelines for staff to manage people who can have restriction on their movements. These plans provide staff with the information on how to care for each person and ensure continuity in care and have been completed to enable staff to carry out their duties. And ensure all aspects of health, personal and social needs were met. All files held were supported by the placing authority care plan and a list of review dates and meetings of regular review meeting and who was in Highbury House DS0000003519.V345261.R01.S.doc Version 5.2 Page 11 attendance at these meetings. Ensuring that people living in the home were involved in regular reviews. Observation throughout the inspection were people living at the home making their own decision about their own lives and include when to go out and managing their own finances. Trips out that morning included going out for lunch and going shopping. The staff were observed asking and assisting people who live at the home where to go and why. The manager stated that each person is given options about where to go on holiday or day trips and then the options available are discussed and destination chosen. The homes AQAA states, “several service users have shown an interest in using the local bus service on their own. We responded to this by working in partnership with the LDS (Learning Disability Service) Community Support Team who have been completing a bus training programme with each interested party to develop their skills in this area”. Many people spoken with confirmed that they choose where they went on holiday and two people said, “ We went to stay with a friend who used to work at the home and who now lives in Portsmouth” and another stated “I am going to Butlins for the weekend soon” and a third person said “I only wanted to go on day trips”. One person living at the home said. “I come to the office whenever I want some money and sign for it”. Records show that each person living at the home has an individual bank account. The homes system of holding money for people living at the home was examined and checked. The cash held was checked and found to be correct. Evidence was provided of a clear audit trail of expenditure, income and people were required to sign for money as they withdraw it. All care plans held risk assessments to cover all aspects of risk. These risk assessments included independent living skills and manual handling risk assessments with assistance’s on using the hoist if required. This information is important to minimize risk. One person living at the home said, “I am doing bus training with staff, then I can catch the bus on my own”. Highbury House DS0000003519.V345261.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): 11/12/13/15/16/17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people living in Highbury House can be confident that the home will promote and provide support for them to access the local community and leisure activities while promoting independence. EVIDENCE: All the people living at the home were interviewed and two were able to say that they were currently planning to move into independent living and the staff was assisting them with independent living skills. This included planning, shopping and cooking their own food. Observation during the inspection was one person discussing with staff the menu for that day, assistance with writing the shopping list, collecting money and going out to purchase items needed. Later near the end of the inspection this person was observed cooking the meal with staff assistance. Highbury House DS0000003519.V345261.R01.S.doc Version 5.2 Page 13 The manager stated that several people currently hold paid employment and one person is also undertaking volunteer work in a charity shop. One person living at the home said, “ I work in a day centre and get paid every week for my work”. The homes AQAA records, Two of the people living at Highbury have paid part time jobs which we actively encourage and one other works in a charity shop as a volunteer two days a week. Evidence was provided by one person’s certificate of achievement displayed in their bedroom. This person confirmed they had attended college. Throughout the inspection many of the people living at the home were observed going out in the community. This included local shops, day centre and one person going out for lunch. One person informed the inspector that they had been to the local Theatre to purchase tickets for a future production. And several people confirmed they had a holiday this year including trips to Portsmouth and going to Butlins soon. One person living at the home said, “I go to a knitting group”. Evidence was recorded in the files examined of input from relatives and friends. The staff confirmed that several people have regular visits from family members and some people visit the families at home. One person said, “I visit my friend in Portsmouth” and another person said, “I went out with my mum yesterday”. One relative spoken with stated that they visit when they wish and these visits are regular. Observation throughout the day was people living in the home participating in daily routines including cooking, cleaning and shopping. This included the two people preparing for independent living and undertaking housekeeping tasks as confirmed in individual Care Plans. Every person spoken with who was able to confirmed that the staff knocks on their doors to gain entry. All care plans seen showed they are based on the promotion of independent living skills and this included all people living at the home having keys to individual bedrooms. Information held on files is used to promote the respect, privacy and dignity of each person living in the home and the home and the grounds are assessable for wheelchair access and included a lift shaft. Further promoting independence and freedom of movement. Highbury House DS0000003519.V345261.R01.S.doc Version 5.2 Page 14 One relative said when asked what the home does well, ”Encourages my relative to go out and become more independent”. Everyone spoken with about the food and who were able made positive comments and several people stated that they go to the local shops to assist with the shopping. One person said, “ I like the food” and another stated, “I can choose the food I like”. One person was observed preparing the evening meal of Toad in the hole, vegetable and potatoes. The lunch meal served provided evidence that individual choices of food were offered. Further observation during this meal served provided evidence that everyone has staff support and specialist equipment if required and this promotes independence at meal times. Highbury House DS0000003519.V345261.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. People living in the home stated that the staff promote their independence and provide very good personal support promoting privacy and dignity at all times. Access to health care is maintained to promote the wellbeing of all who live in the home. EVIDENCE: All personal support is recorded into individual care plans and these are easily accessible for staff and all rooms are single. Each plan also holds a moving and handling plan to assist staff on how each person prefers to be supported. This ensures consistency in the care provided. These care plans are based on assessed needs and evidence was recorded that these are regularly reviewed and then signed. Guidance on personal care is clearly recorded into individual files and this ensures that staff are aware of peoples needs and will promote consistency in care. Highbury House DS0000003519.V345261.R01.S.doc Version 5.2 Page 16 The homes AQAA states, “As the manager I ensure that service users personal choice and preferences are respected and promoted, and details of these are included within their care plans”. A discussion with most of the people in the home confirmed that they agreed that the staff supports them with their personal needs and in a way with is suitable to them. One person said, “They shut my bedroom door when helping me”. Observed during the inspection was one person discussing with a staff member who would assist them with their personal care needs. One person living at the home also requires specialist equipment and evidence was recorded that a Physiotherapist had assist in providing an assessment to ensure the correct equipment was provided. Files examined provided evidence that specialist support is provided and included attendance of Occupation Therapist services. Other files contained letters for hospital out patient appointments and confirming future dates arranged. This ensures that each person living at the home health needs are met and that specialist input is sort. One person stated, “I go to a see the Nurse when I want”. One person had injured their ear recently and records showed that this person attended the local A&E Department and had their injuries attended to. Further case tracking showed that this information was recorded into the person individual file and daily records. The manager confirmed that the home had reviewed this persons risk assessment form to ensure staff are aware on how to prevent further injuries. The medication system was checked during this inspection and found to be well recorded and documented. The home controlled drug record was checked and provided evidence that this was clearly recorded and the correct amount held. Staff designated to administer medication have received some medication training. However the manager confirmed that the home is currently in the process of changing pharmacist, and arranging additional training. One staff member was observed administrating medication and confirmed medication training and shadowing more experience staff until competent to administer medication. Highbury House DS0000003519.V345261.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 available evidence including a visit to this service. The people living at Highbury House can be confident that any complaints or concerns raised will be listened to, acted upon and well managed by the home, which protects the welfare of all. EVIDENCE: The home has a complaints procedure in place and is clearly displayed on the homes notice board. This information included how to contact the CSCI and the process of how a complaint is dealt with including timescales. The complaints procedure is also available in sign to assist people. This information assists people living at the home in how complaints are managed. The Commission had received no complaints. Evident of an old complaint was held on one file and evidence was that this complaint had been dealt with within the given timescales. Also recorded was the action taken and all correspondence held in connection with this complaint. Providing evidence that all complaints would be dealt with. Many of the people living at the home were spoken with and were able to confirm they were aware they could make a complaint and they would approach the management or staff of the home if they had any complaints or concerns. Highbury House DS0000003519.V345261.R01.S.doc Version 5.2 Page 18 Relative spoken with confirmed they were aware of the home complaint procedure but none had needed to use this. One relative spoken with stated that they felt that complaints or concerns raised by people living at the home would be listened to and acted upon. Most staff had completed he Adult Protection training and the manager was in the process of arranging courses for newly employed staff. The manager was waiting to hear about starting the investigators training and records in the homes AQAA that POVA Training for all staff is reviewed regularly. Highbury House DS0000003519.V345261.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. Highbury House continues to maintain a clean and suitable environment for it’s stated purpose and people living at the home can be assured that they will live in a comfortable home that is regularly maintained. EVIDENCE: A full tour of the premises showed that the home is suitable for its stated purpose. The home is well kept, safe and accessible for all the people currently living at the home. Plymouth Highbury Trust employs their own maintenance person who carries out regular everyday repairs. The house was found to be warm and bright and well decorated. The furnishing and fittings were of a good quality and domestic in character. The premises Highbury House DS0000003519.V345261.R01.S.doc Version 5.2 Page 20 were clean hygienic and free from offensive odours and the laundry facilities were separate and a sluice was available. Two people living at the home informed the inspector that the home had purchased new furniture for the lounge area. The manager also confirmed that a new hoist had been purchased and new flooring was being laid in on the bedrooms. The AQAA records that, “We are having flooring replaced in two bedrooms, the laundry room and two of the passageways including the main entrance”. Many staff had completed Infection control training and the manager was arranging an additional course and update for all staff. One person living at the home stated, “I love my home and it’s nice”. Relatives spoken with confirmed that whenever they visit they have found the home to be clean and tidy. One relative said, “My relatives room is always clean and the home is well looked after”. Highbury House DS0000003519.V345261.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): 32/33/34/35/36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are supported by well-motivated and caring staff in sufficient numbers to meet the needs of those currently living at the home. Staff training and supervision are carried out regularly to all staff to ensure that all assessed needs of the people living at the home are met. EVIDENCE: The staff interviewed felt that the home had sufficient staff on duty and observation of staff throughout the inspection showed them to be relaxed, patient and helpful when assisting the people. Some of the people living at the home spoken with confirmed that staff are available and extra staff help them for holidays and trips. Examination of staff files showed that all bar one staff had the required preemployment checks, including CRB (Criminal Record Bureau Disclosure) in place ensuring as far as possible unsuitable staff are not employed. Highbury House DS0000003519.V345261.R01.S.doc Version 5.2 Page 22 One staff member only held one reference on file. The manager stated that he would obtain a second reference for this staff member who had worked at the home for some time. The staff spoken with during the inspection confirmed the training they had attended and course’s planned. These staff members felt that Plymouth Highbury Trust and the Registered Manager promote the staffs training and development. The manager confirmed that some staff either holds an NVQ qualification or will be working toward it. Staff files examined held training certificates including course completed on First Aid, Manual Handling and Food Hygiene. The files examined showed that all newly appointed staff members had received Induction training and were undertaking the Learning Disability Qualification. The AQAA records that all new staff complete an Induction specific to Highbury followed by completing the Learning Disability Qualification Award, which meets the Skills for Care Common Induction Standards. One newly appointed member of staff spoken with confirmed a probation period, CRB clearance and shadowing of experience staff when first employed. One staff member confirmed that the home holds staff meetings and supervision sessions. The staff interviewed felt that they were able to express their view at these meetings. Regular consultation with staff ensures staff can contribute to the running of the home and are aware of the home’s aims and objectives, philosophies of care and promotes consistency and improvement. A thorough training programme is run by the home to ensure that the level of qualification of the staff in the home is maintained. The people living at the home are better cared for because the staff team is trained and competent to deliver care. One staff member said of the staff team, “They are very supportive” and another said, “I really like working here”. People who live at the home made the following comments about the staff, “They are nice” and “They are lovely”. Several relative spoken with said, “Staff are nice, there has been some changes of staff recently but they will contact me about my relative if needed” and another said, “The staff are very nice and my relative is well looked after”. Highbury House DS0000003519.V345261.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): 37/39/42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of this home is very good and ensures that records are effectively maintained. And the staff team are well trained to meet the needs of people living at the home. EVIDENCE: The Registered Manager, Mr Ian Oliver was available throughout the inspection. The manager has now completed the Registered Manager award and an NVQ Certificate. The manager said he hope to do the NVQ Assessors award to assist the staff in the home to complete their NVQ’s. The Quality Assurance system requires some updating and the manager recorded this information onto the homes AQAA form. Highbury House DS0000003519.V345261.R01.S.doc Version 5.2 Page 24 Previous inspection reports show that Quality Assurance surveys are available and these include surveys for families and friends and for people living at the home. The last report also states that these surveys have not been updated since May 2005 and require updating. The homes AQAA states. “We need to revamp our Quality Assurance system to make it more effective and more thorough” and goes onto say under improvements in the next 12 months is to review our Quality Assurance system and compile a new system which is objective consistently reviewed and verifiable. Sampling of servicing records indicated that equipment is serviced regularly and maintained in good working order, including the fire alarm system. Certificates were available on all Health and Safety equipment i.e. hoist ensuring all have been checked. Gas and electrical appliances were being routinely serviced and checked. Electrical systems were being serviced during the inspection by a outside contractor. The fire protection system was well maintained. Maintenance checks are being carried out. Staff are receiving appropriate fire protection training to ensure they have the skills to deal with emergencies. Good health and safety practices reduce any unreasonable risk, affecting people living at the home, to an acceptable level. Highbury House DS0000003519.V345261.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 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 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Highbury House DS0000003519.V345261.R01.S.doc Version 5.2 Page 26 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA39 Good Practice Recommendations Quality Assurance surveys should be undated. Highbury House DS0000003519.V345261.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Highbury House DS0000003519.V345261.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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