Inspection on 16/08/06 for Ingestre Road (12)

This inspection was carried out on 16th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Ingestre Road (12) 05/10/07

Ingestre Road (12) 24/11/05

Ingestre Road (12) 18/05/05

Ingestre Road (12) 14/09/04

Ingestre Road (12) 21/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Ingestre Road (12) 12 Ingestre Road 12 Ingestre Road Tufnell Park London NW5 1UX Lead Inspector Ms Pippa Treadwell-Smith Unannounced Inspection 16th August 2006 09:30 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 Ingestre Road (12) DS0000037254.V287319.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. Ingestre Road (12) DS0000037254.V287319.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ingestre Road (12) Address 12 Ingestre Road 12 Ingestre Road Tufnell Park London NW5 1UX 020 7267 4713 020 7267 0769 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) London Borough of Camden Ms Paula Peake Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Ingestre Road (12) DS0000037254.V287319.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th November 2005 Brief Description of the Service: 12 Ingestre Road is a care home provided by London Borough of Camden. The home is located in Tufnell Park and that is the nearest underground station (Northern Line). The home can be accessed by car via Burghley Road and there is a frequent bus service either to Highgate Road (214, C2) or Tufnell Park (4, 10, 134). The home is sited within a council housing complex and it is sign posted. The home caters for older persons and is able to accommodate 48 people. The home provides full personal care only. Health care needs are met by the community health services. The current charge is £679.00 per week. The accommodation for service users is on two floors, at basement level and ground floor; there is an annexe, which is used for staff sleeping-in accommodation and an office. There is level access into the building and a shaft lift allows access between floors. The facilities are arranged around a large landscaped courtyard. At basement level there is a seating area to the front of the building. The home is divided into six units. Each unit is selfcontained with bedrooms, a small kitchenette, and a sitting-cum-dining room and served by toilets and bathrooms. There is a quiet lounge on the lower floor. Five of the units are home to older persons with long-term care needs, the sixth unit provides specialist intermediate care (rehabilitation). The units are staffed separately with each one having its own dedicated staff. Ingestre Road (12) DS0000037254.V287319.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over the course of one day by two inspectors. The visit lasted a total of 7 hours. The Registered Manager was available and assisted the inspection along with additional input from the staff on duty, service users and visitors. Records such as care plans, daily logs as well as accident and incident logs were examined. A tour of the building was made with attention to the rooms of the service users being case tracked. Some service users were asked for their views of the running of the home and talked about their experiences of living there. Relatives also contributed their comments. Staff were observed carrying out their duties and were involved in general discussion with the inspectors. Prior to the inspection the manager returned a pre-inspection questionnaire, which confirmed some very useful information about the home. Four relatives and two General Practitioners sent back questionnaires giving their views about the home. At the end of the visit feedback was given to the Registered Manager. A comment card about the inspection process has been sent by email for completion and return to the Commission for Social Care Inspection (CSCI) What the service does well: The ethos of the home is to welcome relatives and visitors. One visitor commented, “There is a positive feel about this home. The attitudes are good, needs swiftly addressed and questions answered fully and appropriately”. The current service users say that they like living in the home and feel well looked after. They describe the staff as “caring”, “patient” and “responsive”. The admission process is designed to support service users and not overwhelm them. There are clear and effective arrangements in place to meet the health care needs of the service users. This is especially true in the Rehabilitation Unit, where service users were feeling benefit of the service prior to returning home. There is a clear management structure in place with senior staff being available to answer queries or deal with emergencies. There is a commitment to ensure staff receive appropriate training and development opportunities so that they have the knowledge, skills and correct attitudes to meet the needs of the service users. The manager is very good at ensuring that staff receive appropriate support to improve care practices in the home. The home has a Ingestre Road (12) DS0000037254.V287319.R01.S.doc Version 5.2 Page 6 good track record for staff achieving nationally recognised qualifications in social care. Staff in the home have worked consistently to ensure that the menus are accessible and offer choice and variety in line with medical and cultural needs. 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. Ingestre Road (12) DS0000037254.V287319.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 Ingestre Road (12) DS0000037254.V287319.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 The quality in this outcome area is considered to be good. This judgement has been made using available evidence, including visits to the service. Staff are able to meet the needs and aspirations of the service users through the assessment process. EVIDENCE: The care records of five service users were looked at; two of whom had been admitted since the last inspection. Community care assessments were available and a regulation 26 report for June 2006 provided corroborative evidence. Service users are subject to the care management approach prior to admissions. Copies of social worker assessments are available and it is apparent the home undertakes its’ own assessment of needs. It is clear that every effort is made for prospective service users to have a chance to visit the home prior to moving in for a trial period. Pre-admission visits are carried out by the senior staff team to ensure that the persons needs can be met in the home. The Regulation 26 report highlighted one new service user who had Ingestre Road (12) DS0000037254.V287319.R01.S.doc Version 5.2 Page 9 been in the home for three days. It recorded that there was an assessment from the care manager on file; the manager had visited and the daughter had viewed the placement. A contract was to be signed after the six-week review. This same service user was case tracked as part of the inspection process. The service user confirmed that admission process and was very complimentary about the support received from the staff. The care home offers a rehabilitation service in a dedicated unit. This unit is a joint effort between Social Services and the Primary Care Trust. There is a separate unit with a separate staff team. The regulation 26 report from May records that the unit continues to be run well, with good use being made of the BSL interpreters for sessional professional workers who support the service. There is clear evidence that there is good use of referrals to other health care professionals such as members of the REACH team. On the day of the inspection a rehab assistant had engaged the service users in an exercise class. The staff in the unit are involved in an ongoing assessment process to ensure that service users receive the services they require on discharge. One of the service users agree to be case tracked as part of the inspection process. Although admitted from hospital, the service user felt that they had been given sufficient information about the service and what to expect when they came to stay. This background information was supplemented by the service user guide about the unit, which is available in each room. All relevant information and assessments were available on file. One of the comment cards sent in by a visitor about the rehab unit said, “There is a very positive feel about the home. Attitudes are good, needs swiftly addressed and questions answered fully and appropriately with time taken to explain. Generally speaking the staff appear at ease and involved, working as a team.” Ingestre Road (12) DS0000037254.V287319.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 The quality in this outcome area is considered to be good. This judgement is made using available evidence including visits to the home. It is evident that there has been an improvement in the content of the care plans although further development is required. Service users are reassured that their health care needs are being met. Staff are complying with the policy and procedure for the administration of medication and it ensures safety for the service users. EVIDENCE: In total five care plans were looked at and six service users contributed their views contributed their views during the inspection. Two general practitioners returned comment cards along with four relatives. Care staff were observed interacting with service users whilst carrying out their duties. The daily records were looked. The pre-inspection information provided details on how service users have access to health and remedial services. All service users have a care plan. The regulation 26 report from June records that care staff are still being supported to record more detail on the operational plan to describe exactly how the service user likes things done. The training records show that some staff have attended training on Ingestre Road (12) DS0000037254.V287319.R01.S.doc Version 5.2 Page 11 “Undertaking Assessments with a Person Centred Approach” and “Valuing Memory and Lifestyle”. Both approaches have enable staff to produce improved care plans although further development needs to be going to achieve consistency throughout the staff team as there were gaps noted. Examples of this were seen in several care plans. One care plan did not say what activities the person liked although it was clear that they liked books; however the care plan did not say whether they have library visits. Another care plan made reference to the long term involvement of the Catholic Priest but not how the home would meet the person’s cultural needs i.e. St Patrick’s Day etc. Please see Requirement 1. There were examples where key workers had included all the appropriate information and said clearly how a person liked things done and two staff were identified whose note writing was impressive. The social profiles were found to be short but contain relevant information but these should be continually added to as staff receive more details. The pre-inspection information recorded how service users have access to health care professionals, including GP, district nurse, optician, dentist, chiropody, audiology, occupational therapist, speech therapist and a community psychiatric nurse. There was confirmation from the care records and discussions with service users confirmed that this access is available. Both GP’s who returned comment cards acknowledged that the home communicate sand works in partnership with the respective surgeries for the benefit of the service users. They confirm that staff have a clear understanding of the service user’s care needs. Overall the surgeries are satisfied with the overall care provided by the staff in the home. One of the comment cards recorded “A very good home, caring staff”. Staff were aware of the need to provide extra fluids and fans during the hot weather. The home has a policy and procedure for the administration of medication, which includes the use of homely remedies. Both GP’s have confirmed that service user’s medication is appropriately managed in the home. The preinspection questionnaire identified twelve staff that are responsible for administering medication and the training records supplied with the preinspection information show that they have received training. A small audit of each medication cabinet on the separate units showed that medication administration was safe. Both inspectors received positive comments from the service users who participated in the inspection process. Comments such, as “The staff are so kind”. When the care plans were examined, it was clear that they reflected the values of privacy, dignity, choice and independence. Discussion with service users highlighted that staff respect both privacy and dignity. This was also reflected in the care practice of the staff when they were observed carrying out their duties. Ingestre Road (12) DS0000037254.V287319.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 The quality in this outcome area is good. This judgement has been made using available evidence, including visits to the service. Service users are able to engage in appropriate activities. Family and friends are welcomed into the home. They have a choice of well-cooked and variable meals that meet the dietary and cultural needs of the service users. EVIDENCE: A programme of activities was included as part of the pre-inspection information. Feedback from service users showed that activities are available and they can participate in them according to choice. It has already been highlighted in the report that care plans do not always state how needs are to be met and in particular social and cultural needs but by the next inspection there should be further development. Relatives are encouraged to support service users in activities. Minutes of a resident and relatives meetings shows that the manager is training staff to focus more on the activities of daily living and less on the routine tasks associated with caring for older people. All four the visitors who completed comments cards confirmed that they were welcomed into the home and can visit their relative in private. The visitor’s book shows that the home operates an open door policy and staff were seen Ingestre Road (12) DS0000037254.V287319.R01.S.doc Version 5.2 Page 13 engaging with visitors in a positive way. Visitor’s confirmed that staff are approachable and ready to answer queries or listen to concerns. Discussions with service users and staff highlighted that service users are able to follow their preferred lifestyle. The routines on the individual units are flexible to ensure service user’s needs can be met. Throughout the inspection staff were observed offering service users choices. Since the last inspection the staff in the home have been developing a new menu format. A menu is available on each table in an accessible format for older people with consideration to the size of the print and the colour of the paper. The menus show that there is variety and choice is available as well as medical and cultural needs being met. The manager plans a further development. This will involved the catering staff meeting with a new service user within 48 hours of admission to discuss food choices. The new menu format has been discussed at the relative’s meeting and the feedback has been very complimentary. Ingestre Road (12) DS0000037254.V287319.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The quality in this outcome area is good. The judgement has been made using available evidence, including visits to the service. Service users are assured that their concerns will be listened to and they will be protected from harm by the home’s policies and procedures on adult protection. EVIDENCE: Complaints records were examined. Feedback was received from service users and visitors. Staff were asked about their understanding of adult protection and what their responsibilities were in reporting suspicions or allegations of abuse. Discussions with staff and service users confirmed that service users have information about how to make a complaint. A new style internal complaints procedure has been introduced and this has been discussed in the relatives meeting, which took place a month before the inspection. The minutes from this meeting show that relatives and service users are encouraged to raise concerns. Service users said that they felt confident to talk to the care staff should they feel unhappy with any aspect of their care. All the visitors who returned comment cards confirmed that they were aware of the complaints procedure. One recorded “I have not made a formal complaint but informed staff of damaged clothing in the washing. The response from staff was good. Generally I am very happy.” The in-house policies and procedures on adult protection and whistle blowing are contained within the home’s operational policy. Discussions with staff Ingestre Road (12) DS0000037254.V287319.R01.S.doc Version 5.2 Page 15 confirmed that they had received training in the protection of vulnerable adults. Training records verified this. Staff showed that they understood the concepts of what constitutes abuse and were clear in their responsibility for reporting any suspicions or allegations. Ingestre Road (12) DS0000037254.V287319.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The quality in this outcome area is good. The judgement has been made using all available evidence including a visit to the service. Service users are accommodated in comfortable and maintained surroundings. The overall appearance of the home is clean and fresh. EVIDENCE: The home was toured, including visiting the bedrooms of the service users being case tracked. This was done with their permission. All the rooms in the home for service users are single occupancy. Where assessed as being required, the District Nursing Services have provided specialised cushions and mattresses. Rooms have been arranged to suit the needs of the service users who occupy them. An example of this is reflected in a service users’ care that has a visual impairment. The care plan records that the room must be arranged to keep the service user’s path free from obstacles. The service user concerned confirmed that the staff are very good at keeping his possessions in the same place. The home has both assisted Ingestre Road (12) DS0000037254.V287319.R01.S.doc Version 5.2 Page 17 toilets and bathrooms. Service users said that they found their accommodation comfortable and clean. The home employs separate domestic staff and these were observed being thorough in their duties. The sample of bedrooms showed them to be clean, tidy and fresh. One service user said that “The care here is good and the place is always very clean.” Staff follow cross infection policies and procedures. Protective clothing such as gloves and aprons are available. COSHH training is available. Hand towels and soap dispensers were available in all communal toilets. Overall there were no offensive odours although underlying smells were noted in some rooms but there is a procedure in place to ensure that carpets are clean regularly. Ingestre Road (12) DS0000037254.V287319.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The quality in this outcome area is considered to be good. This judgement has been made using available evidence, including a visit to the service. There are sufficient numbers of staff on duty to meet the needs of the service users. The home is keen to invest in the training and development opportunities for staff. EVIDENCE: The pre-inspection information provided relevant data about staffing and staffing levels. The Regulation 26 report from June 2006 looked at staffing in the home. Staff were observed carrying out their duties. Service users and visitors were asked for their views. Training records as well as staff rotas were looked at. The pre-inspection information recorded that 26 out of 30 staff have an NVQ qualification or above. This is the equivalent of 86 of the care staff complement. The Regulation 26 report shows evidence of the development and staff training, including the registered manager’s award for an assistant manager, NVQ level 3 for a senior care worker and a certificate in dementia care for a care worker. Two of the management staff have attended a dementia seminar. The home is piloting a new induction programme of training launched by Skills for Care. This programme will be rolled out across five London boroughs. The inspection showed that training records are up-todate. There is clear evidence that staff are attending training, which is relevant to their work and to meet the needs of the service users. Staff Ingestre Road (12) DS0000037254.V287319.R01.S.doc Version 5.2 Page 19 administering medication have attended training and where updates are required these have been provided. There is a clear management structure in place with a manager and a team of assistants; therefore there is always a senior member of staff on duty. There are dedicated catering, laundry and domestic staff. The feedback from the service users and the visitors is that there are sufficient numbers of staff deployed around the home; and the rotas confirmed this. The staff group is balanced to enable service users a choice of male, female and age related preferences. The Regulation 26 report confirms that there is a full complement of staff but a recruitment drive is taking place across all four homes. A sample of recruitment files were looked at some months prior to the inspection. The providers are re-organising how the personnel records will be kept, which will be an improvement. The Commission is satisfied that the provider operates a thorough and robust recruitment and selection process Ingestre Road (12) DS0000037254.V287319.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 The quality in this outcome area is considered to be good. This judgement is made using all available evidence including visits to the service. The home is being effectively managed. Arrangements are in place to promote the health, safety and welfare of service users. A system is in place for self-monitoring through formal as well as informal means. EVIDENCE: The home is managed by an experienced and suitably qualified manager. The manager has been in post for more than two years and has successfully completed the fit person process for registration. Since being in post she has achieved NVQ 4 in Care and management. She is supported by a management team and also receives support and supervision from the Project Manager for Residential Services. Supervision in the home is ongoing. The regulation 26 report for June 2006 reflects that the manager is proactive in ensuring that supervisions for staff are done regularly. The manager has been instrumental Ingestre Road (12) DS0000037254.V287319.R01.S.doc Version 5.2 Page 21 in giving ongoing development assistance to seniors in order to improve their practice when doing supervision. Appraisals are due to be completed and the manager confirmed that she is signing them off. Poor staff performance is recognised and managed in a supportive way using effective management tools. The service has circulated satisfaction survey forms to every relative or friend of all the service users in the home. Visitors were asked to comment on the welcome they receive, the degree of privacy and about the quality of the communication with the home. Any critical feedback is addressed by the home. A satisfaction survey amongst the service users will also be conducted annually. There are polices and procedures on handling service users monies and valuables. The pre-inspection information shows that service users personal finances are managed in the most appropriate way. Two service users are subject to Money Care, two have solicitors to advocate on their behalf, one is under the Court of Protection and two are subject to Guardianship Orders. The London Borough of Camden holds service user’s savings and the financial department bank in separate accounts for each service user, therefore any interest accrued is on an individual basis. All service users have access to their full personal allowance. A sample of financial records were looked at and found to be accurate. Accounts allow for an audit trail. The home has a health and safety policy in place and staff undertake appropriate training. Risk assessments are in place for COSHH. A contract is in place for the collection of clinical waste. Records show that equipment is serviced and there is a system in place to report repairs. During a tour of the premises there were no hazards observed. Water temperatures are regulated. A system to test alarm bells is in place and staff are aware of how to respond in the event of a fire. A health and safety inspection was carried out in June 2006. The latest environmental health officer’s report shows that the hygiene in the kitchen is satisfactory. Ingestre Road (12) DS0000037254.V287319.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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 X 3 X 3 3 X 3 Ingestre Road (12) DS0000037254.V287319.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. 1. Standard OP12 Regulation 15(1)16(2 )(n) Requirement The care plans for all service users must include their preferences in respect of: routines of daily living likes and dislikes of food, meals and mealtimes leisure, social activities and cultural interests religious observances personal and social relationships. There has been an improvement in the care plans but further consistency is required. Timescale for action 31/12/06 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 Ingestre Road (12) DS0000037254.V287319.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Camden Local Office Centro 4 20-23 Mandela Street London NW1 0DU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ingestre Road (12) DS0000037254.V287319.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. 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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