Inspection on 01/11/07 for Leylands Rest Home

This inspection was carried out on 1st November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Leylands Rest Home 06/02/07

Leylands Rest Home 07/02/06

Leylands Rest Home 15/06/05

Leylands Rest Home 20/01/05

Leylands Rest Home 29/07/04

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

CARE HOMES FOR OLDER PEOPLE Leylands Rest Home 16/18 Leylands Lane Heaton Bradford West Yorkshire BD9 5PX Lead Inspector Karen Westhead Key Unannounced Inspection 10.15a 1st November 2007 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 Leylands Rest Home DS0000001228.V340718.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. Leylands Rest Home DS0000001228.V340718.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Leylands Rest Home Address 16/18 Leylands Lane Heaton Bradford West Yorkshire BD9 5PX 01274 543935 01274 770035 leylands@starl.fsbusiness.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Annette Nerteley France Mrs Annette Nerteley France Care Home 17 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (17), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (1), Physical disability over 65 years of age (1) Leylands Rest Home DS0000001228.V340718.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th February 2007 Brief Description of the Service: Leylands Rest Home is a large four-storey inner through terraced property, which has been adapted to provide a care home. It is in Heaton, in Bradford. The home is close to the shops and other community facilities. The home is registered to look after older people who have a diagnosis of dementia or memory loss. The home creates an atmosphere, which allows residents and their families to come to terms with, and learn to live with the effects of dementia in a positive way. This is done is a way which preserves residents dignity and self-respect. Bedrooms are a mix of single and double rooms. These are on three floors of the building. There are stair lifts to bedrooms on the first floor. However at the present time rooms on the second floor can only be reached by climbing a number of steps. Therefore these rooms are not suitable for residents with limited mobility. The owner (who is also the registered manager) is looking at ways to address this, to make access to these rooms better. All the communal areas used by residents are on the ground floor. There are two lounges and a dining room. Residents have a choice of three areas to sit, as the dining room has easy chairs, which are also used. Leylands Rest Home is on a main road and is easy to get to by bus. There is a small garden area to the front of the house. There is a ramp providing level access to the front door. The fees range from £374.71 to £415.31 week. Additional charges include hairdressing, private chiropody, newspapers and some selected activities. Leylands Rest Home DS0000001228.V340718.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was done by one inspector and had not been prearranged with the manager. The inspector arrived at 10.15am and left at 4.20pm. At the end of the visit, the deputy manager was told how well the home was being run and what needed to be done, if anything, to make sure the home meets the required minimum standards. The reason for the visit was to make sure the home was being run for the benefit and well being of the residents and in line with requirements. Before the inspection information received about the home was reviewed. This included the number of reported incidents and accidents, the action plan provided following the previous inspection and reports from other agencies such as the fire safety officer’s report. The manager was also asked to complete an Annual Quality Assurance Assessment (AQAA) prior to the visit being made. This form is used by the manager to carry out a self-assessment of the service being provided and to give factual information about such things as staffing levels, policies and procedures and details of residents living in the home. During the visit the inspector observed staff and resident relationships, spoke to all the residents, four staff and the deputy manager. Resident care plans, risk assessments, healthcare records, meeting minutes, staff training and staff recruitment records were also some of the documents looked at. Surveys were sent to the home to be given to residents, staff and relatives. Pre paid envelopes were also provided so that those filling in the surveys could return them directly to the Commission for Social Care Inspection (CSCI) office. At the time of writing this report none had been returned. The manager carries out her own quality assurance by sending out questionnaires to relatives and there is regular contact between them. Staff see relatives and families as a valuable asset to the home and encourage them to be involved and make comments about the service being provided. In many situations residents cannot give their views, so relatives and families are asked to do that on their behalf, to be their ‘voice’. What the service does well: The home is well managed by a competent manager who is supported by a deputy and a team of skilled staff. Residents looked settled and content. The layout of the building allows them to move freely from room to room if they wish, therefore not restricting them to one area. Leylands Rest Home DS0000001228.V340718.R01.S.doc Version 5.2 Page 6 Paperwork is comprehensive and therefore staff know what they need to do to meet residents needs. The senior team is continually looking at their recording systems to find ways to improve these. For example the plans of care for residents have been changed to make the record more user friendly and detailed enough to give an accurate picture. The residents, their families and friends are actively encouraged to share their views about the home and how it should be run. This is one way staff can be sure the home is being run in a way which benefits the residents. Health and personal needs of each resident are fully met. Staff are given support and guidance by other health care professionals, including district nurses, the mental health team and social services. Staff know their own limitations and when to ask for additional support and advise. For example, the home does not provide nursing care, but this does not mean residents, who develop an illness or condition, cannot still live in the home. If there is agreement with the resident’s doctor and the home can continue to provide care with nursing support from other agencies then this is done. Health and safety is seen as important and risk assessments have been completed to make sure the home is fit for purpose and safe. The layout of the home means all residents have their own private space, even for those sharing a bedroom, and this they can furnish themselves. This is limited due to the amount of space available but such things as their own bed, armchair, sideboard or occasional table had for some become a cherished item of furniture. Those rooms seen were highly personalised with pieces of furniture, pictures and shelves to display ornaments and photographs. Residents are given ample opportunities to be involved in activities and recreation. There is a structured programme including ‘discussion groups’ which look at every day events in the news and local papers. Residents and their relatives are offered the chance to be involved in the completion of plans of care and are invited to reviews when the care package is looked at to make sure the home is continuing to provide what is needed. The staff team also support families and friends to try and help them come to terms with their relative’s condition and the ‘loss’, which is sometimes, felt when a person is diagnosed with dementia. What has improved since the last inspection? What they could do better: Leylands Rest Home DS0000001228.V340718.R01.S.doc Version 5.2 Page 7 Leylands Rest Home continues to provide a good standard of care for residents. Staff are to be complimented on their commitment and hard work, which benefits the residents and makes sure their quality of life is good. 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. Leylands Rest Home DS0000001228.V340718.R01.S.doc Version 5.2 Page 8 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 Leylands Rest Home DS0000001228.V340718.R01.S.doc Version 5.2 Page 9 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 (Standard 6 - N/A, the home does not provide intermediate care) People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Residents and relatives have enough information about the home to decide if it will meet their needs. EVIDENCE: The admission process allows for prospective residents to visit the home before deciding to move in. Because of the dementia some residents have then their relatives are often involved in the process and are given the information they need to be able to decide if the home is suitable. The home does not accept emergency admissions. However, they rarely have vacancies. When a vacancy arises the room is allocated and taken quickly. All residents are provided with a contract on admission. Four plans of care were looked at in detail. These included the most recently admitted person, a resident with poor mobility and a resident who has high Leylands Rest Home DS0000001228.V340718.R01.S.doc Version 5.2 Page 10 dependency needs. All of them included a pre admission assessment. Assessments are carried out by the manager and deputy, who are trained and competent to carry out the visit. Residents are visited in their own home (including other care homes), or in hospital. This means the assessor can get a good idea about the type of care they need. The prospective resident and their relative can also ask questions about the home and what moving in will mean to them. A judgement is then made about whether the home can provide the care needed. The admissions process gives prospective residents the opportunity to spend time in the home before moving in. On admission, where possible, an individual member of staff is allocated to give the resident information, special attention, help them to feel welcome and comfortable in their surroundings and ask any further questions. The plans of care were looked at and cross-referenced with other records, including accident forms, medication sheets, risk assessments and daily diary sheets (which record what the resident has done during the day and night.) The Statement of Purpose and Service User Guide provides enough information for residents and their relatives about the home and what they can expect. Staff said they had read through the information with some of the residents and were heard throughout the visit explaining where they were and what was happening next. Bedrooms are single and double. There is permanent screening in double rooms. This means residents can have privacy whilst being attended to, by staff, and can have time alone if they choose, without being disturbed. The inspector talked to all the residents and did not hear anything which suggested they were not content or being well cared for. The staff team are qualified and experienced to work with the resident group. Staff understand the cultural and diverse expectations of the residents and work within these. Residents have access to the advocacy service where necessary. Leylands Rest Home DS0000001228.V340718.R01.S.doc Version 5.2 Page 11 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 People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Health, personal and social care needs are fully met. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Residents at Leylands Rest Home receive very good personal and healthcare support, which is ‘person centred’. The Statement of Purpose and Service User Guide explain the type of care the home offers. The staff team are skilled and knowledgeable about the needs of the residents and deliver care in a professional, caring and competent way. Plans of care detail the personal and healthcare needs of each resident and how staff will meet these. Staff work in partnership with other professionals to make sure residents are receiving the best possible care. For example, the district nurses in the area visit to attend to residents who require dressings changing or a prescription injection. Leylands Rest Home DS0000001228.V340718.R01.S.doc Version 5.2 Page 12 The management of pressure sores is good, where necessary residents have been provided with specialist mattresses and cushions to be used to prevent pressure sores developing. There are is equipment in bathrooms to encourage residents to retain their independence. The manager reviews this regularly to make sure the home can accommodate any changing needs. Staff have received training in the use of this equipment. The moving and handling of residents and how staff do this is of importance when considering whether a resident can remain at Leylands. If there is need for a hoist or other portable equipment the building is limited. However, the manager is keen to look at all the options available before taking the decision to discharge a resident. Residents who have moved in from the area keep their own doctor. Others are automatically registered with a local surgery. There is a team of district nurses who know the residents and the residents trust. Regular reviews and health appointments are seen as important and systems are in place to make sure these happen, including optical, dental and chiropody treatments. Staff are alert to any changes in mood, behaviour and general wellbeing of each resident. Plans around health are in place and records are carefully updated to give an accurate account of what is required and what has been done. Examples of good practice were seen with regard to residents who are prone to falling; developing pressure sores or is at risk of malnutrition. Risk assessments are carried out to identify what the risk is and how this is can be minimised. Falls are monitored and preventative measures are taken to make sure residents are protected, specialist equipment is available and staff receive adequate training to use it. There is a good medication policy in place. Staff understand the procedures and work to it. An example of good practice was seen when medication was to be given out at lunchtime. Residents were given the chance to finish their meal without being disturbed when being given medication. Leylands Rest Home does not provide nursing care, however admissions are seen as long term whilst ever the staff team can provide the care required. The wishes of each resident about terminal care and the arrangements they want after death is sensitively discussed with residents or their relatives. Leylands Rest Home DS0000001228.V340718.R01.S.doc Version 5.2 Page 13 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 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. As far as possible residents at Leylands Rest Home Fold make choices about their lifestyle. Social, cultural and recreational activities meet the resident’s expectations. EVIDENCE: Staff focus on each residents right to live the life they choose. Staff do not impose their views on residents but support them in ways, which might improve their quality of life. Staff make sure residents rights are protected. For example residents are treated with respect and dignity and have access to a range of community resources. Relatives are asked to share their views about the running of the home and their comments are taken seriously. Routines are very flexible and residents make choices about their lives. For example residents have control over when they get up and go to bed, whom they spend time with and whether they join in the structured activities. Leylands Rest Home DS0000001228.V340718.R01.S.doc Version 5.2 Page 14 A main meal is provided at lunchtime. Meals are served in the main dining room. There are staggered sittings so that residents who need additional help are given the attention they need. At this busy period there are enough staff to make sure residents dine in a relaxed way with no fuss. Residents were offered tabards to wear during their meal, to protect their clothes. Staff did this in a friendly way, always facing the resident to tell them what the tabard was for. However if residents wish, they can sit elsewhere in the home to dine. If residents have any difficulties with their meals staff discuss this and come up with solutions. Staff stayed with residents to make sure they were able to finish their meal and receive the nutrition required. Residents who due to their method of eating or the effects of a disability are helped to retain their dignity and sense of self-esteem in a way, which is not demeaning. There is a varied menu available and residents have a choice at each mealtime. Snacks and drinks are provided throughout the day and night. Staff try to encourage residents to eat a healthy diet and monitor weight loss and gain. Staff complete a ‘nutritional screening’ form for residents to assess if they are at risk of being undernourished and if so steps are taken to make sure they receive high calorific foods and snacks and if necessary food and drink intake is recorded. The inspector watched the main meal being served and talked to residents after the meal. The presentation and delivery of the food was very good. For residents who need a soft diet, each component of the meal was liquidised and presented on the plate. Therefore retaining the tastes and textures, which made the meal more appealing. Visiting is unrestricted and relatives were seen coming and going throughout the inspection. They are asked to sign in and out for fire safety reasons and said they understood why this was important. Visitors said they always felt welcome at the home. Activities and recreation are a main feature in the home. All organised activities are recorded and monitored to make sure residents have access to things they enjoy, that activities are age appropriate and that they cover a wide variety of themes to give everyone an opportunity to take part. For residents who prefer not to join in staff record any activity they have been involved in. Staff are sensitive to residents wishes and this is also considered when reviewing the social aspects of individual care. Staff play an active role in promoting activities in the home. In addition to organised events staff were seen interacting with residents on a regular basis. No resident was passed by a member of staff without acknowledgement. This ranged from a conversation, to a smile and a touch of someone’s hand. Leylands Rest Home DS0000001228.V340718.R01.S.doc Version 5.2 Page 15 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, 17 and 18 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Residents and relatives are able to raise complaints and have access to a complaints procedure. Their rights are protected and they are safe. EVIDENCE: There have been no complaints to the manager since the last inspection. The complaints procedure is available for residents and relatives. Copies of the adult protection procedures and the local authority adult protection procedures are kept in the office, and are available for staff to read. Staff showed a good awareness of what they should do if they thought residents might have been subject to any form of abuse and were able to identify the different types of abuse possible. Training had also been given. Leylands Rest Home DS0000001228.V340718.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 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The design and layout of the home allows residents to live in a safe, wellmaintained and comfortable home. EVIDENCE: There is limited parking to the rear of the home, otherwise staff and visitors use on street parking. Leylands Rest Home is a no smoking home. The home is generally well maintained and the standard of decoration and furnishings is satisfactory. Bedrooms are personalised and reflect the tastes of the resident using it. Many of the residents had brought cherished items of furniture, photographs and ornaments with them to make their room feel like their own. Leylands Rest Home DS0000001228.V340718.R01.S.doc Version 5.2 Page 17 The layout of the building means groups of residents can meet together in one of three communal areas. Residents can meet with friends and relatives in their bedrooms. Bathrooms and toilets are located around the home. These were found to be clean and tidy. There are locks on the doors and residents can use the facilities in private. On the day of the visit a new boiler was being fitted in the home, so the availability of hot water was not assessed. However, the contractor had arrived mid morning to work around residents needs. Despite the water being turned off at intervals the staff were able to provide a full service. The home is well lit, clean and tidy. One bedroom was identified, as having a slight unpleasant odour, otherwise there were no offensive odours. This shows that staff are alert to the needs of residents and attend to personal care in an effective way. Outside, the home has a small front garden and ramped access to the front door. Information provided by the manager showed that all safety certificates and servicing was up to date and valid. Staff have received the necessary training to make sure they know what to do in case of fire and some have been trained in health and safety procedures. Leylands Rest Home DS0000001228.V340718.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 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Staff are trained, skilled and enough staff are on duty to support the residents. EVIDENCE: All the residents looked relaxed and comfortable in the company of staff. There are enough staff on duty throughout the day and night. Staff have been trained meaning they have the skills and knowledge to deal with the needs of the resident group. All staff have an accurate job description, which sets out their roles and responsibilities. The staffing structure and duty roster are based around the needs of the residents and not led by staff requirements. For example there are maximum staffing numbers around busy periods in the day. There is a good recruitment procedure that makes sure only staff who are suitable to work with vulnerable people are appointed. The deputy manager confirmed that all staff employed in the home had been through a criminal records bureau check. All new staff work alongside a senior member of staff. All staff are recruited subject to a probationary period. This is extended if necessary until the manager is confident they are the right person for the job. Leylands Rest Home DS0000001228.V340718.R01.S.doc Version 5.2 Page 19 Two staff files were looked at in detail. All the necessary checks had been carried out. Leylands Rest Home DS0000001228.V340718.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, 34, 35, 36, 37 and 38 People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The management of the home is based on openness, respect and commitment. The manager is competent and has the necessary skills and qualifications to run the home properly. EVIDENCE: The manager is qualified and has a significant amount of experience of working with older people. The manager is supported by a team of dedicated staff. The manager has a clear vision of what the home provides and what they want to do to further develop the service. Policies and procedures are written in a way, which follows ‘best practice’. Equality and diversity issues are considered when staff are working with residents. Leylands Rest Home DS0000001228.V340718.R01.S.doc Version 5.2 Page 21 The home carries out an annual quality assurance survey and has systems in place to review its performance as a whole. Staff work practices and performance is discussed during their supervision sessions with senior staff. The views of residents, relatives and staff are listened to, valued and acted upon. There are safeguards in place for the correct management of resident’s money. Record keeping relating to resident care and maintenance of the home are very good; therefore staff know what they are doing. These are kept securely and staff know what they have to do to comply with the requirements of the Data Protection Act. The plans of care are written with involvement of residents and their relatives as appropriate. The manager and staff team have a good understanding of the risk assessment process and this is taken into account in the running of the home. A common sense approach is used to minimise risk without restricting the movements of residents. Health and safety systems are regularly reviewed and are kept up to date. Leylands Rest Home DS0000001228.V340718.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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 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 3 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 4 4 4 3 3 3 4 3 Leylands Rest Home DS0000001228.V340718.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. Refer to Standard Good Practice Recommendations Leylands Rest Home DS0000001228.V340718.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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