Inspection on 05/03/07 for Holly Lodge Secondary Treatment Centre

This inspection was carried out on 5th March 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holly Lodge Secondary Treatment... 24/02/09

Holly Lodge Secondary Treatment... 07/02/06

Holly Lodge Secondary Treatment... 09/08/05

Holly Lodge Secondary Treatment... 01/03/05

Holly Lodge Secondary Treatment... 28/09/04

Similar services:

Littledale Hall Therapeutic Community

Bennett House

Padgate House

Mary & Joseph

Westcliffe House

Richards House

Hamer Cottage

Turning Point (Hoole Road)

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

CARE HOME ADULTS 18-65 Female Focus 361 Clifton Drive North St Annes on Sea Lancashire FY8 2PA Lead Inspector Mrs Gwen Miller Unannounced Inspection 5 ,6 ,12 March 2007 10:00 th th th Female Focus DS0000059590.V324237.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 Female Focus DS0000059590.V324237.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. Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Female Focus Address 361 Clifton Drive North St Annes on Sea Lancashire FY8 2PA 01253 723144 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) craiglands@pierpoint.co.uk Mr John Noel Grady ACIB Lisa Dignan, Registration applied for. Care Home 16 Category(ies) of Past or present alcohol dependence (16), Past or registration, with number present drug dependence (16) of places Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may only provide care to the following categories of service user: 16 (sixteen) females with a past or present drug/alcohol dependence 7th February 2006 Date of last inspection Brief Description of the Service: Female Focus formerly registered in the name of Craiglands is a Primary Treatment Centre for women with substance dependency or addiction. Situated in a large tastefully modernised Victorian building in St. Anne’s - on – Sea, the home is close to local shops and amenities and is a short walk from the promenade. Female Focus is close to good transport links. The unit is part of the Pierpoint Group, which provides effective intervention through, assessment, detoxification and treatment for adults who have drug and/or alcohol addictions. The home is specifically aimed at caring for women aged 18-65 who wish to address their addiction. Female Focus provides a holistic approach to residential and community based addiction treatment and enables people to identify strengths and weaknesses so by the end of the programme the person will have an understanding of the changes needed in relation to their addiction. At the time of these visits (March 2007) the information given to the Commission showed that the fees for care at the home are from £625 per week, with added expenses for hairdressing, toiletries, tobacco and sweets. The people who live at Female Focus refer to each other as “peers”, this report makes reference to people as service users, this is in agreement with the home. Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of this home has been carried out over the period since the previous inspection 7th February 2006. This is to give an overall picture of Female Focus using evidence and information gathering, in the form of a pre inspection questionnaire, letters to and from the home during that period and comment cards from service users. The inspection also included two site visits to the home, the initial being unannounced. A third visit was to Pierpoint House where staff files and the homes accounting systems were seen. A fourth visit was to Female Focus, to give feedback of the whole inspection process to Lisa Dignan, the manager. On 5th March 2007, eight service users were accommodated at the home. The inspector spoke with all service users, nursing and care staff, the manager of Female Focus and operational manager of Pierpoint, Julie Townsley. Eight comment cards were received at the Commission for Social Care Inspection, these were from service users. A further six service user questionnaires were completed at the home, comments from all of these are included in this report. Case tracking (whereby the inspector focuses on a small number of service users and examines their care, from admission to the present time) was carried out for three people. Part of the visit included looking at daily notes and information about the home and service users. Time was spent observing the workings of the home and how staff members supported people in general. The inspector joined the daily “community meeting”, where views and any concerns are shared between service users and counsellors. Time was spent with the administrator at Pierpoint House and the home’s accountant who explained funding and charging arrangements. A good lunch was sampled and shared in the company of service users The inspection included a tour of the premises. What the service does well: In line with the home’s policies and procedures, Female Focus tries to make sure that there is equal care given to all service users, considering their individual choices and preferences and giving equal support to all, irrespective of their race, gender, disability, sexuality, age, religion or beliefs. Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 6 There is equal consideration given to prospective employees, there are male and female staff between the ages of 18 and 65 years working at the home, training and development programmes are offered to all staff. All service users spoken with, said they felt well cared for. Comments included “I can’t fault the house as it works for me” and “this home has saved my life”. A collection of thank you cards from previous service users are displayed in the lounge areas. 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. Female Focus DS0000059590.V324237.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 Female Focus DS0000059590.V324237.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): 1,2,3,4,5 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Detailed information is provided by the home, this allows people to make informed choices whether or not the home will meet their needs. Full assessments of needs are carried out for all service users to ensure the home is the right place for them and provide them with the right sort of care. EVIDENCE: The Home’s written information contains all the relevant information needed for prospective residents to make an informed choice when they are considering using the service for their rehabilitation from drugs or alcohol. This information is clearly set out, easy to understand and prospective service users are invited to contact the home for clarity of any points, if needed. All prospective admissions are dealt with by an Admissions Team, based in St. Annes who also carry out detailed assessments of needs for each service user. These may include information from other agencies involved in the person’s care as well as the person themselves. Information is handled confidentially and accessed on a need to know basis. Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 9 A “face to face” interview is carried out at the home, where prospective service users are invited to look around, meet with staff and other peers, before deciding whether or not to make Female Focus their choice in rehabilitation. These can be with relatives if the service user wishes. Service users confirmed they had received information saying” I was sent an information pack detailing everything I needed to know”. Service users also said they had spoken with staff, either in person or on the telephone, prior to admission. Some said they had visited the home and spoken with others, so they knew “how the home worked”. Case tracking showed that assessments may include details of past alcohol / drug abuse, any psychiatric input and previous treatments as well as family history and offences. Contracts are drawn between the home and service user to confirm their understanding of and agreement to the rules of the home. Contracts are also made between the purchaser or funder of the service whether private or local authority. On admission information packs are given to each resident to further explain how the house is run, and a key worker is assigned to the service user. Female Focus DS0000059590.V324237.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. Care plans are well detailed which ensures that all carers are aware of the individual’s needs. EVIDENCE: Case tracking and records showed very detailed care plans for all service users following the 12 step approach. These are completed with, and signed by service users and their key workers. Care plans address changing needs and constant changing goals as service users progress through their rehabilitation. Service users complete “assignments” each day, these reflect on their personal feelings and progression in the programme. All care plans, including risk assessments reflected the care needed by the service users and provided by the carers. Service users meet as a “community” daily, this allows an open forum for concerns and peer support, conducted in a safe environment. Counsellors are Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 11 present and available to further discuss issues following the community meeting. Service users said they felt such meetings to be “helpful, part of their living with others again and responsible for their actions”. Good records are kept of both one to one and group meetings, these are also used by counsellors at staff change over to ensure all carers / counsellors are working in a similar way and towards the same goals for each service user. These records also highlight if someone is having particular problems or issues with their programme or alert staff to physical or mental health needs. The rules of the treatment programme are such that service users are not always able to make independent decisions, as a member of the house, service users are given specific tasks and responsibilities to undertake. All spoken with said they acknowledged the restrictions imposed as a necessary part of the programme. Such restrictions include not leaving the house without permission and not to have spontaneous visits from friends and family. Rules and boundaries are clearly documented in the home’s information and service users sign to confirm they understand them and agree to abide by them. The home operates a strike system whereby having received three strikes, a service user would be asked to leave. All spoken with were clear about this rule which had been explained to them before signing in agreement as part of the rules of the house Female Focus provides a safe place for treatment following detox, all spoken with said they felt safe in the home. A more independent lifestyle, including risk taking is available at Holly Lodge, this is where service users progress to following their stay at the Female Focus. Female Focus DS0000059590.V324237.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. Links with families are maintained, these support and enrich resident’s rehabilitation. Meals offer choice and variety but also cater for those with special dietary needs. Activities are in place to enable residents to enjoy their leisure time. EVIDENCE: Again on this site visit, it was noted that information about rights and responsibilities regarding daily routines and house rules is provided prior to admission to the home. There are clear rules regarding alcohol and drugs, and certain visiting restrictions, which form a key part of the contractual agreement. It is clearly stated within the homes Statement of Purpose that contact with friends and family cannot be made for the first week of treatment to prevent people feeling distracted from the programme. Visiting is restricted to Sundays to ensure that group sessions and therapeutic duties are not Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 13 interrupted. Domestic tasks are carried out on a rota basis, service users said that this system is fair and works well. Social skills and personal development opportunities are incorporated into the programme although these remain supervised. Access to the local community is restricted to ensure that this does not detract from the programme of treatment. Service users understood these restrictions and were advised they could go out for walks, go down to the beach and visit local shops. They also understood that on returning to the home, necessary checks had to be carried out for their own health and safety. Questionnaires confirmed that service users understood the reasoning behind house rules and regulations. Comments included “to keep order in turn helps everyone in their recovery” and “abiding by rules makes for a safe, caring environment.” When asked about decisions in what to do each day, comments were “this is an addiction treatment centre, so most of the day is structured but we make decisions about our life”. Activities listed in the pre inspection questionnaire include art therapy, guided relaxation, line dancing, karaoke, disco’s, walks, beach walks, music groups, physical activities group, shopping, church visits, AA/NA meetings, shiatsu, acupuncture and sleepy tea relaxation tape. The home has sought the views of service users in how these are rated by them, most gave positive feedback A telephone is available for service users, calls are time limited so that all can have use of this service. Comments about the reasoning for this were “to avoid too many outside influences and keep the focus on treatment” and this “allows peers to be considerate to other users”. The home’s meals are delivered from Pierpoint house, which is the primary treatment unit in the service. Questionnaires received from service users, confirmed that the food served at the home is good, plentiful with good choice. Chocolates and sweets are limited to encourage health and nutrition, comments indicated that service users think this is reasonable. These included “so we are not filling ourselves with unhealthy diets, limited sweets are a treat. I think that is good”. Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have access to equal health services as those living in the community, therefore their health needs are met. Medication systems are safe ensuring the service user’s safety. EVIDENCE: It is not always possible for service users to receive personal support in the way they prefer as the nature of the rehabilitation programme includes bringing back order and structure into their lives, therefore routines cannot be flexible. This is explained in the home’s information, on initial visits and is re enforced during stages of the programme. Service users said this had been explained to them and they understood the reasoning for this. When asked to rate the standard of care received at the home, two service users scored 10 out of 10, two scored 9 out of 10 and two scored 8 out of 10 Case tracking on this inspection, showed that care and personal support is provided in keeping with the changing needs of the individual, as they proceed Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 15 through the programme. Service users also complete their own written records on how they view their progress. A medical assessment is carried out for each service user at the beginning of their stay at the home. This contains information on past and current medical conditions and substance abuse. G.P.’s and appropriate medics monitor the health of service users throughout their stay at Female Focus. All questionnaires confirmed that service users were satisfied with the level of health care accessible to them. It is not always possible for service users to retain, administer and control their own medication in the way they prefer, as the nature of the rehabilitation programme does not allow this. The home has a good medication policy and systems, medication appeared to be stored safely and medication records were seen to be up to date. Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system and evidence that service users feel that their views are listened to and acted upon. EVIDENCE: The home uses a good clear complaints procedure which is included in the home’s Service User Guide. All service users confirmed they knew who to speak to, if unhappy with their care or if they had a problem. In comment cards sent to service users from The Commission for Social Care Inspection, when asked “Do the staff treat you well?” 4 out of 6 said “always”, 1 replied “usually” and 1 replied “sometimes”. There were no negative responses. When asked “do the carers listen and act on what you say?” 4 out of 6 replied “always”, one said “usually” and one said “sometimes.” There were no negative responses. The Commission for Social Care Inspection has received no concerns / complaints since the previous inspection. Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 17 Staff are trained in “The protection of Vulnerable Adults” , this includes “Whistleblowing”.This forms part of the staff induction process. The pre inspection questionnaire showed that future planned training for all staff includes the subjects of “self harm” and “eating disorders”, to further protect service users. Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The standard of environment in this home is good, providing service users with a safe and homely place to live. EVIDENCE: The home was registered with the Commission for Social Care Inspection in March 2004. The home provides seven double bedrooms and two single bedrooms. The use of double bedrooms is in line with good practice for this client group to prevent isolation of service users who may be vulnerable due to their addiction. There are three lounges within the home, which provide adequate communal space. The house also has a separate dining room and visitors area. Again on this site visit, only minor areas for repair were noted, the manager agreed to remedy these without delay. The service users spoken with were happy with their surroundings and felt that the home was comfortable and provided a safe environment. All confirmed that Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 19 there was plenty of hot water for showers. All questionnaires received from service users, confirmed that the house was warm enough and the laundry facilities were adequate. On touring the premises all areas of the home were seen to be clean and free from odours. Laundry facilities are appropriately sited and the home has policies and procedures in respect of control of infection. Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34,35,36 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The service users are supported by competent and qualified staff however recruitment practices need to ensure that appropriate police clearances are in place prior to employment, to protect service users, also that staff files are always accessible to the Commission for Social care Inspection. EVIDENCE: When consulted about their relationship with staff members, service users spoke well of the staff team, their commitment and personal qualities, such as, being genuinely interested in their work and in the progress of individuals. New staff are given a two week induction period during which time they are supernumerary to the staff quota, their role includes shadowing a competent staff member, familiarising themselves with aims of the home, their role responsibilities, policies and procedures. Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 21 A new staff member was interviewed, she had a good job description, a clear understanding of her role in the home and was very enthusiastic about working at Female Focus. The pre inspection questionnaire provided the information that at present the home employs five first level registered nurses, seven care staff, six of whom have achieved National Vocational Training to level 2 or above, thereby reaching a target of 85.7 . On the site visits of 5th & 6th March 2007, staff files were not available to the inspector, the registered person needs to ensure that staff records are at all times available for inspection by any person authorised by the Commission for Social Care Inspection in keeping with regulation 17 of the Care Homes Regulations 2001. A requirement has been made regarding this. Staff files showed that on application for employment, references are taken up, employment histories are listed as well as educational qualifications. Criminal Records Bureau checks and Protection of Vulnerable Adult clearances are applied for. During this site visit, one staff file did not hold these although CRB clearance had been applied for. The operational manager immediately applied for POVA first clearance and agreed that the staff member would not work until this clearance was obtained, also that she would work under supervision until appropriate CRB clearance was received by the home. A requirement has been made regarding this. At present, formal supervision is not carried out, the manager said she has devised a new supervision system for both care and nursing staff, this is to be implemented this month. Appraisals are also to be introduced, this month. However staff said they felt well supported with help from management always on hand if needed. Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The home reviews aspects of its performance through consultation, which includes seeking the views of service users, thereby ensuring the home is run in their best interests. Good procedures are in place to safeguard the financial interest of service users. EVIDENCE: The current manager is undergoing registration at present, having worked in her role for 12 months. Lisa Dignan has experience of working with people recovering from alcohol and drug addiction and was observed to take an active part in the group meetings held during the site visits. Lisa Dignan displayed a good knowledge of the care and emotional needs of the service users and the therapies used by the counsellors. Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 23 There are clear lines of accountability and responsibility ensuring all staff are confident if the roles in the staff team. A service user questionnaire was issued to everyone at Female Focus, to monitor the service provision and enable individuals to air their views on how the home meets their needs. The results were given to the Commission for Social care Inspection and comments have been noted throughout this report. The home has a good record in meeting National Minimum Standards for this particular client group and compliance with the Care Homes Regulations 2001. The home has gained Investors in People Award. The pre inspection questionnaire showed up to date maintenance certification and associated records. Policies and procedures are in place and used in the daily running of the home, these ensure a safe working environment for staff and service users Accounting systems are good, service users personal spending monies are held secure but easily available to them when needed, records are kept of each person’s allowances, spending and balance. During this visit, one service user had a query regarding her post office monies, fees and charges for her stay. The home’s accountant and administrator offered a meeting to help her with her query. The Responsible Individual for the home or other persons responsible for the management of the organisation needs to visit the home at least once a month and prepare a written report, in keeping with Regulation 26 of the Care Homes Regulations 2001. A requirement has been made regarding this. Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 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 3 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 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 X 3 X 3 X 2 3 X Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA41 Regulation 17 Requirement The registered person must ensure that staff records are at all times available for inspection by any person authorised by the Commission for Social Care Inspection. The Responsible Individual for the home or other persons responsible for the management of the organisation must visit the home at least once a month and prepare a written report. The home must ensure that staff files include the requirements listed in Schedule 2 , Regulation 7,9,19 of the Care Homes Regulations 2001 Timescale for action 01/04/07 2 YA41 26 01/04/07 3 YA34 19 01/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Female Focus DS0000059590.V324237.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!