Inspection on 08/08/07 for Inglewood House

This inspection was carried out on 8th August 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Inglewood House 09/05/06

Inglewood House 05/01/06

Inglewood House 21/09/05

Inglewood House 18/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Inglewood House Inglewood House 56 Middle Gordon Road Camberley Surrey GU15 2HT Lead Inspector Suzanne Magnier Unannounced Inspection 8th August 2007 11:15 Inglewood House DS0000013686.V337446.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 Inglewood House DS0000013686.V337446.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. Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Inglewood House Address Inglewood House 56 Middle Gordon Road Camberley Surrey GU15 2HT 01276 64776 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) The Regard Partnership Limited Mrs Elizabeth Gail Hayes Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2006 Brief Description of the Service: Inglewood House is a semi detached house situated in a residential area of Camberley, and is within a few minutes walking distance from the town centre. The home is registered to provide care for up to 12 individuals in the category of younger adults. The accommodation is provided over two floors, with communal areas on the ground floor and bedrooms on the ground and first floor. All bedrooms are single, with a wash hand basin. There is a pleasant rear garden, which is accessible to all individuals. Parking is mainly on-street parking. The current fees range from £800.00 -£1500 per week Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the care home was an unannounced ‘Key Inspection’. Some additional standards were assessed and have been included within the report. Ms S Magnier Regulation Inspector carried out the inspection and the registered manager and deputy director represented the service. For the purpose of the report the individuals using the service are referred to as people living in the home. The inspector arrived at the service at 11:15 and was in the home for five hours. It was a thorough look at how well the home is doing. It took into account detailed information provided by the homes manager, and any information that CSCI has received about the service since the last inspection. The inspector spent time talking with people living at the home in order to seek their views about the home and the care they receive. Responses to questionnaires that the Commission had sent out and written comments have been included within the report. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Documents sampled during the inspection included the homes Service User Guide, care/person centred plans, daily records and risk assessments, medication procedures, staff recruitment profiles, staff training records, and several of the services policies and procedures. Following a previous key inspection in May 2006 and a random inspection in November 2006 the service has met all the requirements made. The home has submitted the Annual Quality Assurance Assessment (AQAA) prior to the inspection, some details of which have been added to the report. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. From the evidence seen by the inspector and comments received, the inspector considers that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. The inspector would like to thank the people living in the home, the staff and the directors for their time, assistance and hospitality during this inspection. Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: It has been recommended that an overall improvement to the care plans would be to ensure that all the goals, aspirations and care plans for individuals are signed by the author and dated. This would give a clearer audit and review of the goals people have achieved and what they may wish to do. A worn carpet is replaced in one individual’s bedroom and the four fire doors, which were not closing correctly, must be repaired in order to ensure the safety and welfare of all people in the home. Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 7 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. Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 8 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 Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 & 4. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. Arrangements are in place for a care needs assessment for individuals to ensure that their needs are assessed and identified before admission to the home. Prospective people have sufficient information to make an informed choice if they would like to live in the home which include trial periods of stay in the home if they choose. EVIDENCE: The inspector sampled the admission and assessment procedure for a person who had recently been admitted to the home and noted that the procedures were clear in determining that the care home could meet the needs of the individual. It was evident through sampling the documentation that the individual, their relatives and other representatives had been included in the care assessments, and had visited the home on several occasions prior to the individual moving into the home. The ethnicity and diversity of the individual was reflected in the assessment for admission and it was evident during the inspection that the home was aware of the needs of all individuals from differing cultures and faiths. Inglewood House DS0000013686.V337446.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, 8 & 9. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The home has robust care plans and risk assessments. The documents were well recorded to ensure that the supported person’s changing needs, safety and wellbeing were being met. Some improvement to the documentation has been recommended. People make decisions regarding their life and participate in the running of their home. EVIDENCE: The inspector sampled two care plans. Both of the care plans were noted to be well written and clear to demonstrate the care needs of the individual. Agreed working guidelines were in place to offer individuals a consistent and supportive plan of care. The care plans were person centred and detailed the individuals preferred choice of name, their relatives and friends contact details, the individuals hobbies, likes and dislikes, how the individual communicates, what objects, Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 11 places or people are significant in their lives, their personal history’s and what support and assistance they would like and need from staff. The inspector observed staff openly engaging with individuals who did not use formal speech to communicate with an underlying knowledge of the individual and the way they communicated. This enabled the individuals to put their views across, make their own decisions and be understood by the people around them. One person at the home told the inspector that they go to work and had been living in the home for a long time and felt very happy. They told the inspector that they felt they would not be where they are today if it hadn’t been for the home’s support. They also made decisions to keep their room locked when they were not at home and made decisions about their life and what they wanted. Other written comments included ‘…is always given a choice about what he does. He can speak with his key worker or shadow worker’, ‘I always do what I want, and if I was unhappy I’d talk to ….’ Whilst sampling the care plans the inspector noted that there were agreed working practices and well documented risk assessments available for all staff to follow when supporting people with their personal care, mobility, support with meals, support during and after seizures, using the wheelchair and when out and about away from home and for any individual hazard identified in the individuals daily living. The daily records written by staff were well written and documented clearly the support and care the person had received and how they had spent their day. Evidence of reviews of care plans was sampled in order to ensure that the changing needs or support the individual requires is documented and the individual’s needs are met. It has been recommended that an overall improvement to the care plans would be to ensure that all the goals, aspirations and care plans for individuals are signed by the author and dated. This would give a clearer audit and review of the goals people have achieved and what they may wish to do. The inspector was advised that staff meet with people individually to find out what they would like to help with in the home and it was observed that some individuals were encouraged and supported to take part in the running of their home, which included feeding Tilley the dog, helping in the kitchen and garden and helping to lay the tables in the garden for the midday meal, discussing weekly menus and kitchen duty rotas. It was observed that one person was sitting on the edge of the garden swing seat and when the inspector sampled their care plan it indicated that a hazard had been identified that the person had a history of losing their balance. It was recommended that the mobility risk assessment be updated to include the use of the garden seat and the homes manager and staff promptly updated the risk assessment to include the details. The manager explained that this update Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 12 would be brought to all the staff’s attention in the handovers held on each shift in order to ensure the individuals safety. Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17. Quality in this outcome area is excellent. This judgement has been made using a range of evidence including a visit to this service. The home promotes and maintains individual’s involvement in their local community and offers opportunities for personal development, appropriate activities and employment and assists in maintaining and supporting friendships. People are encouraged to be involved in the running of the home and maintaining their daily living skills. A choice of a healthy diet is provided. EVIDENCE: It was evident during the inspection that people in the home were comfortable and relaxed in their surroundings and the atmosphere in the home was calm and orderly. During the inspection it was noted that individuals had a variety of diverse needs and it was apparent that staff ensured that all people in the home were supported in a way, which reflected and promoted peoples individuality, which is to be commended. Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 14 The inspector sampled the homes diary and the activity timetables. The documents indicated that individuals took part in a variety of leisure and work activities, which included meeting and maintaining contact with friends and family, speaking on the telephone, having holidays, working in a boarding kennels, going shopping, doing housekeeping tasks for example laying the table, helping in the kitchen, having support with financial budgeting, learning about cosmetics, going to church, having resident meetings to talk about the home, looking after the rabbits and Tilley, ten pin bowling, ice skating, day trips to places of interest for example Sea Life, going into town and the seaside and going to the cinema. It was evident through listening and chatting with individuals that they enjoyed the activities and for some they were able to tell the inspector how pleased they were of their individual achievements and independence of lifestyle. One person told the inspector that they were going out on Friday for burgers and coke and another person showed the inspector their colouring. During the inspection the inspector observed that one staff member had received a telephone call with regard to new opportunities for some individuals and the AQAA advised that the home is proactive in researching new available activities, social groups and colleges to offer more choice. During the inspection it was noted that the service has strong links with the individuals family, friends and health care professionals. During the tour of the premises the inspector noted that one person had a variety of sensory equipment in their bedroom and was enjoying the calming atmosphere whilst lying on their bean bag. It was observed that some people had special bonds with each other. The staff demonstrated that they were aware of people’s special attachments to each other and these were appropriately managed. In addition there was respect for peoples own space for example individual’s wanting to stay in their rooms and then mix with people in the house on their terms, having meals on their own and also having their own chairs in the lounge area to sit where they preferred. The inspector noted that staff respected peoples privacy by knocking before entering any bedrooms, adhereing, where possible to gender specific care and offering personal care in a respectful manner. People cultural and religious beliefs were respected by staff which included saying prayers with an individual at bedtime and supporting individuals to attend local churches. Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 15 The homes fridge was well stocked with fresh dairy products and vegetables. The midday meal was served in the garden, as it was a hot sunny day. The lunch consisted of sandwiches and special diet for one individual. The garden furniture and shading ensured that all people outside were protected from the sun and also had adequate space and facility to enjoy their meal. The inspector sampled the homes menu, which was displayed and demonstrated that a varied choice and nutritional diet was offered. The inspector noted that a tin of dog food had been left in the fridge, uncovered and this was brought to the attention of the individual who took care of the dog. The staff advised the person who promptly covered the tin and used a label to indicate when the tin had been opened. Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 16 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 a range of evidence including a visit to this service. The home has consistent recording and documentation to evidence that individuals attend health care appointments to ensure their wellbeing and welfare. The homes medication procedures are robust to ensure the safety and wellbeing of all people in the home. EVIDENCE: The person centred plans developed by the home clearly document the ways in which individuals undertake their personal care needs and where assistance is provided how staff should assist the person with their care. Preferences on choice of clothes, having a bath or a shower, opportunities to choose what to wear, what time to get up and go to bed were demonstrated. The health care needs of individual’s were clearly documented and included appointments to the optician, chiropody, dentist, physiotherapy, ear, nose and throat specialists and GP appointments. One individual had chosen to retain the services of their GP who they have known for a long time. It was noted that the records indicated that reviews by the local multi agency healthcare Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 17 professionals were undertaken. One visiting healthcare professionals comments included ‘the people are well cared for and I have no concerns about this home. Staff are usually very patient with the clients and report ongoing changes if an intervention is required by me. Good overall service but try to keep up the good standards by recruiting experienced people in future as well’. ’ The medication cupboard is located in a safe place within the home and is locked to ensure security and safety. The home has a monitored dosage system in place and a medication policy and procedure. The inspector sampled the medication administration charts and noted that staff administering medication initialled them. A staff member was observed administering medication in a safe and competent manner. The controlled drugs were checked regarding amount and storage and all documents and accounting was in order. Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 18 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 a range of evidence including a visit to this service. People living in the home are encouraged to able to express their concerns and have access to a complaints procedure and are protected from abuse and have their rights protected. EVIDENCE: The home has a clear complaints procedure, which has also been adapted in differing formats for people living in the home. One comment card received from a person living in the home stated ‘If he was unhappy he would talk to someone.’ The AQAA indicates that no complaints had been received since the previous inspection. Whilst sampling the complaints log the inspector noted that there was a detailed clear chronology of events for example dates and details of correspondence and outcomes regarding complaints previously received by the home. Written comments received by the commission regarding the homes complaints process included that the homes complaints procedure was available to people in the home and people knew how to make a complaint and actions would be taken to address any concerns they may have. The inspector sampled that the home has the local authorities multi agency procedures for safeguarding adults and the manager advised that the home follows these procedures. The AQAA and the manager stated that there had Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 19 been no safeguarding referrals under the safeguarding adults procedures. The inspector noted that the home has a whistle blowing policy and procedure, which is available to staff in order to safeguard people in their care. Staff spoken with during the inspection demonstrated an understanding of the procedures for safeguarding adults and training records detailed that staff receive safeguarding adults awareness training. Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 20 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 a range of evidence including a visit to this service. The physical layout of the home enables the supported person to live in a safe environment. The home is generally clean, pleasant and hygienic throughout. EVIDENCE: During the tour of the premises the inspector noted that the majority of areas of the home well decorated. The laundry area was viewed as cluttered and the manager explained that it was due to be redecorated but no decision had been reached regarding the colour. Special attention had been made to promote a pleasing environment with homely ornaments and décor. The manager explained that new sofas were on order as the current sofas were old. The home employs a cleaner for 4 hours a day, five days a week and the home was generally clean and free from malodour. Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 21 One comment card received from a person living in the home stated ‘House is clean, excellent meals I am happy’. One persons bedroom carpet was worn and a malodour present in the room. A requirement has been made that the carpet is replaced with a covering of the person’s choice. The manager advised the CSCI by email promptly after the inspection to advise that costing estimates were being sought and the replacement carpet would be attended as soon as possible. Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to provide 24hour support to individuals living at the home. The home has a robust system for the induction, training development and recruitment of staff to ensure that individuals needs are met appropriately and safely. EVIDENCE: The home currently employs nineteen care staff. On the day of the inspection there were five care staff on duty. All staff were observed as skilled in supporting the people in their care and were knowledgeable regarding the specific needs of individuals to ensure their safety, well being and offer reassurance. One comment card received from a person living in the home stated ‘Staff treat me pretty good, I am happy here’. Another comment from some visiting the home stated ‘I assume that staff have the right skills and experience they are very caring, nice and helpful. I don’t know how to make a complaint but I would figure it out if I needed to. I think that the service supports people to live the life they chose. They create a lovely atmosphere where people are Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 23 happy. They have a smile on their faces and they seem to like what they are doing. The home has a recruitment and selection policy, which incorporates equal opportunities. The inspector sampled two staff recruitment checklists that had been supplied to the home by the organisation. The checklists indicated that staff had job descriptions in order that they were clear about their roles and responsibilities. There was evidence that prospective staff had received faceto -face interviews and references and CRB clearances had been obtained. Records indicated that staff had received induction and mandatory training. The AQAA advised that eleven out of the nineteen staff have achieved an National Vocational Qualification Level 3. Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The management and administration of the home is robust and the home is run in the best interests of the individuals living in the home. The home has a quality assurance process to seek the views of people connected with the service. Some health and safety aspects need to be improved. EVIDENCE: The pace of the home was designed to meet the needs of all individuals living in the home. It was evident through observation and talking with individuals in the home that the manager had good knowledge about managing the care home and had the skills and experience to ensure the safety and well being of all persons in the home. Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 25 People’s views about the service were sought and there was evidence to support that the home had taken the views in account. During the tour of the premises it was noted that at least four fire doors were not shutting correctly which was viewed as a potential hazard. A requirement has been made that all fire doors in the home are checked to ensure that they are closing properly in order to ensure peoples safety at home. The manager promptly telephoned an appropriate person who visited the service that evening to repair the doors and CSCI were advised by email the following day that all the doors had been adjusted to close correctly. The home undertakes health and safety checks and has infection control measures in place. The accident and incident book was sampled and evidenced that the home have reported the the CSCI under Regulation 37 notifications events that affect the well being and welfare of individuals in the home. Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 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 X 2 X Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 27 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 2 Standard YA24 YA42 Regulation 23.(2)(d) 17 (2) 12 Requirement A worn carpet is replaced in one individual’s bedroom. The four fire doors, which were not closing correctly, must be repaired in order to ensure the safety and welfare of all people in the home. Timescale for action 08/10/07 13/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations It has been recommended that an overall improvement to the care plans would be to ensure that all the goals, aspirations and care plans for individuals are signed by the author and dated. This would give a clearer audit and review of the goals people have achieved and what they may wish to do. Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Inglewood House DS0000013686.V337446.R01.S.doc Version 5.2 Page 29 - 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!