Inspection on 22/11/07 for Humphry Repton House

This inspection was carried out on 22nd November 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

Humphry Repton House 17/12/08

Humphry Repton House 06/10/06

Humphry Repton House 01/11/05

Humphry Repton House 28/04/05

Humphry Repton House 19/10/04

Humphry Repton House 06/04/04

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

CARE HOMES FOR OLDER PEOPLE Humphry Repton House Brentry Lane Bristol BS10 6NA Lead Inspector Vanessa Carter Unannounced Inspection 22nd November 2007 08:30 X10015.doc Version 1.40 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 Humphry Repton House DS0000020250.V352413.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 Older People. 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. Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Humphry Repton House Address Brentry Lane Bristol BS10 6NA 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) 0117 9592255 0117 9709301 humphryrepton@aspectsandmilestones.org.uk admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mrs Deborah Jane Stone Care Home 44 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (44) of places Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate up to 10 persons aged 50 years and over with dementia Manager must be a RN3 or RNMH on the NMC register May accommodate one person aged 46 at the time of registration Date of last inspection 6th October 2006 Brief Description of the Service: Humphrey Repton House is a 44-bedded care home operated by Aspects and Milestones. Aspects and Milestones are a Bristol based, non-profit making charity, with several other care homes and small group homes in the city. Forty-two of the beds are for permanent placement, plus there are two rooms that the home use to offer a short-term respite service. The home is registered to provide both personal and nursing care for persons who have dementia. In addition the home is registered to take up to ten people between the ages of 50-65 with a dementia. Humphrey Repton House is set in large grounds and is a purpose built care home. The facilities have been extended to offer additional beds and a separate day care facility. It comprises four wings plus a service area where the kitchens and laundry are sited. Each wing has its own separate lounge and dining area as well as bathing facilities. The three wings in the original part of the home have now been upgraded but the supply of some new items of furniture is till awaited. These improvements will mean that the original part of the home will be in line with the new build. Although the home will retain its name, it will also be known as the Bristol Dementia Centre. The cost of placement at the home ranges between £504.00 - 820.00 per week and is based on individually assessed needs. Additional charges for a number of items are listed in the home’s brochure. Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection visit took place over one day. Evidence has also been obtained from a number of other sources, namely: Information supplied by the Home Manager in the Annual Quality Assurance Assessment (AQAA) Information supplied by 3 people who live in the home in CSCI survey forms (two completed with relative support) Information supplied by relatives in CSCI survey forms Information that has been received by CSCI since the last inspection CSCI survey form returned for one GP Touring the home Talking to the home manager and the deputy manager Talking to staff Observations of the people who live in the home and their interaction with other people and the staff team Looking at staff and care records Looking at other documentation and policies of the home What the service does well: The home provides good information to people who enquire about the service. enabling them and their families to make an informed choice about the home and what it has to offer. The pre-admission assessment processes ensure that placement is only offered to those whose needs can be met. The home’s care planning processes ensure that each person who lives there, is cared for as an individual and their health and personal care needs will be met. The home has previously demonstrated that medication procedures are safe. People who live in the home have the opportunity to participate in a range of meaningful activities and are provided with a well balanced diet. People who live in the home and their relatives can be assured that any concerns they have will be listened to and acted upon. Staff awareness of safeguarding adult issues ensures that the people who live in the home are protected from harm. People who live in the home will do so in surroundings that are comfortable and safe and are well maintained. Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 6 Improvements in the stability of the staff team ensures that the people who live in the home are cared for by staff who are familiar with their individual care needs. The home is well managed, and the people that live in the home benefit from a safe and secure environment. 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. Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good information to people who enquire about the service, enabling them and their families to make an informed choice about the home and what it has to offer. The pre-admission assessment processes ensure that placement is only offered to those whose needs can be met. EVIDENCE: The Statement of Purpose and Service Users Guide (home brochure) is unchanged since the last inspection, both meet the standard required and enable people who want to know about the home to decide what the home has to offer. Any prospective person who wishes to live in the home is also provided with a copy of the home’s brochure – this is currently in the process of being updated. Copies of the brochure are displayed in the main reception now that the refurbishment of this area has been completed. Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 9 Each new person is provided with a “Licence Agreement” or a statement of terms and conditions. This sets out the terms and conditions of occupancy and the fee’s payable. The home has robust pre-admission assessment processes and the documentation completed for one of the recently admitted people who live in the home was examined. The assessment tool is a comprehensive document and provides a clear picture of the person’s specific needs. When local authorities are involved in the arrangements for placement, a care plan and health needs assessment is obtained as part of the information gathering process. The homes admission process ensures that placement is only offered to those people whose needs they can meet. The home is registered to provide placement for people with a dementia, who may also have challenging behaviour needs. The staff team are appropriately skilled to care for this client group. Most people are also frail and elderly, and therefore can also have a full range of other physical and sensory disabilities. Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s care planning processes ensure that each person who lives there, is cared for as an individual and their health and personal care needs will be met. The home has previously demonstrated that medication procedures are safe. EVIDENCE: Care planning documentation for four people who live in the home were looked at, in order to determine how the home plan to meet the assessed needs of a person. Detailed plans are prepared for each person. Where people are admitted from hospital, a very detailed history of the person’s specific needs and behavioural traits, is provided by the nursing staff. This ensures that staff have very useful information about the person and how they have been cared for previously. The home plans each person’s care based on an individual basis and their needs are recorded in the form of “things I need help with”. The plans cover a range of different aspects of health, personal care, cognitive abilities and difficulties, personality and social care needs. The plans are Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 11 written in collaboration with the person’s family or representatives. The plans are generally reviewed and altered where necessary on a monthly basis. In each file there is an overall summary of care needs and this provides a quick guide to specific needs. Since the last inspection the home have improved the practice of reviewing and recording the changes made. The home’s GP completed a CSCI survey form and stated that they were “satisfied with the overall care provided to residents within the home”. They also added “the permanent staff are exceptional at dealing with difficult situations”. This GP was able to confer with the people who live in the home in private, that the staff demonstrated a clear understanding of the service users needs, that medications were managed properly and that any specialist advice is incorporated in the persons care plan. The plans are supported by a number of general risk assessments, including waterlow assessments that measure the risk of developing pressure sores, and manual handling risk assessments. Also specific risk assessments relating to an individual are completed for example in respect of behavioural traits or specific health care risks. Following on from the manual handling risk assessments the home devise a safe system of work for each procedure so that staff know exactly what they are to do and what equipment is needed. Daily notes are completed for all people who live in the home - they were detailed and provided a clear record of care given and any other events that have occurred. The home has previously demonstrated that they have safe procedures in place for the ordering, receipt, storage, administration and disposal of medications. No changes have been made to the systems in place, no concerns have been raised, and therefore procedures were not re-examined. During the inspection, staff were observed interacting appropriately with the people who live in the home, were friendly and caring and were vigilant of those who behaviour may affect others, or who wander. Since some people who live in the home have a short span of concentration, it was evident that the staff will work with the person rather than try and keep them doing what they want. Personal care was given with respect to dignity and privacy, and bedroom doors are fitted with privacy locks. The home provides placement for people who are dying, and have produced a well thought out booklet for relatives that may help them with the grieving process. The manager and staff referred to one such person who was poorly – the GP and the family were consulted several times throughout the course of the visit. Staff representatives will always attend funerals and pay their respects to the families. Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home have the opportunity to participate in a range of meaningful activities and are provided with a well balanced diet. EVIDENCE: The home has two activity organisers, one full time and one part time. There was an opportunity to speak to both during the course of the inspection. Support workers are also responsible for engaging the person they are looking after in meaningful activities and examples seen during the visit include playing skittles with one person and completing a jigsaw. A number of different activities are arranged on a daily basis. Some activities are provided by outside entertainers and during the summer months outings are arranged. Activities include music sessions, a monthly church service, pets as therapy, birthday celebrations and other such celebrations. Alternative therapies such as aromatherapy and reflexology are available but (there is an additional charge for these services. The staff would provide the necessary support to enable any person to continue with other activities and arrangements outside of the home, but this needs to be on a planned basis. People who live in the home have daily care regimes and can get up or go to bed when they wish. They are also able to move independently around the Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 13 home as they are able. People can choose where they want to sit and where they take their meals. This freedom means that at some times of the day the home can appear to be chaotic and messy. The midday meal- time arrangements were observed. Each person is offered a visual choice at each mealtime, to ensure that for that meal they eat what they choose. Some people liked to wander around with their meal in their hands whilst others needed to be assisted to eat their meals. Many of the people needed regular prompting and encouragement to help themselves. The mealtime was unhurried and would appear to be chaotic to an outside visitor, however the people who live in the home are receiving the service that meets their needs. There was good interaction noted between the staff and the people who live in the home. This evidences that those who live in the home are cared for as individuals and this is good practice. One relative had previously complained that loud and inappropriate pop music is played during mealtimes – the manager has ceased this practice. Background, classical music was playing on one unit. Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home and their relatives can be assured that any concerns they have will be listened to and acted upon. Staff awareness of safeguarding adult issues ensures that people who live in the home are protected from harm. EVIDENCE: The home’s complaints procedure is included in the homes brochure and is now displayed in the main reception area. The relatives who responded via the CSCI survey forms each stated that they were aware of the homes complaints procedure and one relative spoken to, said that they had raised concerns with the managers and the issues were being addressed appropriately. Since the last inspection the home have dealt with a small number of complaints and there was clear evidence in the complaints log of the actions taken by the manager, to try and bring about a resolution to the complaints. One complaint was made directly to CSCI, and this was referred to the service provider for resolution. The outcome to this complaint has just been finalised. The home also keeps a record of all the compliments it receives – there were a great many of these and comments included “……looked after my relative with such kindness and respect” and “helped us to understand and cope with those last days”. The majority of compliments are received after the death of someone. Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 15 The home has a policy on the protection of vulnerable adults (POVA) and is line with locally agreed protocols. Copies of the current Bristol City Council “No Secrets” Guidance are available for the staff. Discussion with manager and other staff members centred around the impact that one person’s behaviour is having upon the lives of the others who live in the home. Advice must be sought from the Safeguarding Adults Coordinator as a matter of priority, to ensure the safety of the other people who live in the home. The home arranges abuse awareness training for the staff team, and plans several sessions throughout the year. Staff spoken to during the course of the inspection, said they had done this training and provided appropriate responses when questioned about ‘serious’ abuse matters. They were fully aware of their responsibilities in protecting the people who live in the home from any form of harm. Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home will do so in surroundings that are comfortable and safe and are well maintained. EVIDENCE: Humphrey Repton House is a purpose built care home that is able to accommodate up to 44 people, two of the beds being available for short-term placements, whilst the other 42 are for permanent placement. On the same site there is also a self-contained day care centre and offices for the domiciliary care services. The home is surrounded by pleasant gardens that are secure and are designed with “sensory stimulation” in mind. A “Wall of Smiles” is being made by the “Friends of Humphrey Repton” where tiles are decorated and displayed to remember all previous people who lived at the home. The main entrance into the home is now fully operational and contains comfortable seating, the visitors signing in book, a display of information and Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 17 photographs of the whole staff team. The main front door is secured out of hours and the doorbell is programmed into the deck-phones carried by the qualified staff. The home is arranged as four wings, three being in the original part of the home and the forth being in the new section. Each area has its own communal areas, assisted bathrooms and toilets. The three wings are situated around a central courtyard, each containing ten bedrooms. All bedrooms have a wash hand basin and doors, leading out on to the garden area. Some of these bedrooms have already been redecorated whilst others will be done as and when they become vacant. The communal areas have been refurbished and redecorated, but some items of furniture are still awaited. The flooring has been replaced throughout, and new doors fitted between each wing and the bedroom areas. The forth wing is in the new building. Each of the 12 bedrooms has en-suite facilities of a wash hand basin and toilet, and they are furnished with specialist nursing beds. The two short stay rooms are now located in the new part of the home. The new laundry room is equipped with two large washing machines and one tumble dryer, and all personal and home laundry is attended to in-house. The new kitchen is fully equipped. Both facilities are located in the link corridor between the two areas of the home. The home was generally clean and tidy throughout, although as previously mentioned, it did become messy during the meal time. There were no unpleasant odours. Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements in the stability of the staff team ensures that the people who live in the home are cared for by staff who are familiar with their individual care needs. EVIDENCE: Although the home continues to have a high staff turnover, they have been able to recruit more staff than those who leave. There is an ongoing programme of staff recruitment and in the meantime agency staff are supplied to fill shifts. The home has negotiated a contract with an agency and generally the same agency workers are supplied. Relatives who completed CSCI survey forms and also spoke to the Inspector were concerned about the use of agency staff. The manager has already greatly improved the situation from how it was on the last inspection and continues to take active steps to establish a full staff complement. Qualified nurses and care staff are supported by housekeeping and catering staff, in meeting the daily living needs of the people who live in the home. The home has a team of approximately 43 employees made up of qualified nurses and support workers. Some work full time whilst other part time. Each wing has its own team coordinator and team leaders. Of the 30 support staff 16 or 53 have already achieved at least a level 2 National Vocational Qualification in Care. Four further staff have been Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 19 earmarked to start NVQ 2 in the future. Some of the qualified staff have completed the A1 Assessor award. One of the qualified nurses is a registered trainer and facilitates ‘team development days’ on each of the four wings. The staff files of all newly recruited staff members were examined and evidenced that the home follows safe vetting procedures. An application form has to be completed by all applicants, they are interviewed and they will only start work once two satisfactory written references from previous employers have been received, POVAfirst clearance and CRB disclosures have been confirmed. All new staff will complete an induction- training programme at the start of their employment, to ensure that they are aware of the homes procedures and are competent in all areas of their work. Part of this programme will be undertaken at Aspects and Milestones head quarters whilst competency in the job role, is confirmed by home staff. It is mandatory for all new staff to complete moving and handling training, fire awareness and health and safety. Three new staff members spoken with during the course of the inspection said they had been allocated a mentor to help them settle in to the job and confirmed the induction arrangements. The home maintains a staff training file for each staff member and examples of training that staff have attended includes COSHH (care of chemical substances), abuse awareness, values based training, manual handling, food hygiene, fire awareness, dementia care, first aid and abuse awareness. Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, and the people that live in the home benefit from a safe and secure environment. EVIDENCE: The Home Manager, Mrs Deborah Stone has been in post for four years and is a registered nurse in mental health. She is currently working towards an NVQ Level 4 in Management. Mrs Stone’s hours of work are Monday to Friday. The home also has a deputy manager, also a registered nurse, who supports the Home Manager in the running of the home, along with three lead nurses, and a team of registered nurses. On-call cover arrangements for the weekends and ‘out of hours’, is provided by the manager and her deputy. Full staff team meetings are held on a monthly basis and examination of the meeting notes evidenced that staff opinions and suggestions are valued. The Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 21 manager will also hold qualified staff meetings on a regular basis. Support groups for relatives are held on a once a month basis and these are arranged by one of the team coordinators. The relative who had raised concerns with CSCI about a number of issues, supplied a copy of the meeting notes, as evidence of the concerns felt amongst a lot of relatives. Discussion with another relative, at the time of this inspection visit, confirmed that the manager was dealing with the issues seriously and that actions had already taken place to resolve a number of the matters. The home has a number of processes in place to monitor the quality of their service and to ensure that the service remain appropriate to the needs of the people who live in the home. A senior manager from Aspects & Milestones completes quality assurance monitoring visits, each month and submits a report to CSCI. A full resident and relative survey is completed on an annual basis, using an external agency – this is due again in December 2007. Care plans are reviewed on a regular basis and meetings are held regularly to capture relatives and staff views and where appropriate, the views of the people who live in the home. The home looks after small amounts of personal monies for a number of people, and records are kept of transactions in and out of the accounts. The records were not checked on this inspection however have previously been in order when audited. The manager completes regular audits of the home in respect of health and safety. The fire records were not examined during this inspection, but the home have previously demonstrated that all the necessary weekly, monthly and quarterly checks are completed. Those staff spoken with during the inspection confirmed that they had received recent fire training. Risk assessments are carried out for all safe working practices and records are maintained when any restrictive measures need to be taken to secure each person’s safety. Humphry Repton House DS0000020250.V352413.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 Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Humphry Repton House DS0000020250.V352413.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 OP18 Good Practice Recommendations The home to seek the advice of the safeguarding adults coordinator regarding the impact the behaviour of one person, has upon the lives of other people who live in the home. A report to be submitted to CSCI of the strategies that have been put in place to minimise the impact. Humphry Repton House DS0000020250.V352413.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Humphry Repton House DS0000020250.V352413.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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