Inspection on 20/02/07 for Maplestead Road

This inspection was carried out on 20th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Maplestead Road 30/05/07

Maplestead Road 13/12/05

Maplestead Road 01/07/05

Maplestead Road 03/03/05

Maplestead Road 02/09/04

Maplestead Road 29/03/04

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

CARE HOME ADULTS 18-65 Maplestead Road 36 Maplestead Road Dagenham Essex RM9 4XR Lead Inspector Ms Harina Morzeria Key Unannounced Inspection 20th February 2007 10:00 Maplestead Road DS0000027907.V330727.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 Maplestead Road DS0000027907.V330727.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. Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maplestead Road Address 36 Maplestead Road Dagenham Essex RM9 4XR 0208 595 7645 0208 595 7645 jade@outlookcare.org.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) Outlook Care Ms Jadesola Ezerioha Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include 2 named people over 65 years of age. Date of last inspection 13th December 2005 Brief Description of the Service: Maplestead Road is a purpose built home in a residential area of Dagenham. The property is a large house, which offers a service for six adults with mental health needs. The service users at Maplestead Road require supervision and encouragement from staff in most aspects of daily living. It is the aim of the home to promote independence with the service users to improve their daily living skills. The home is well equipped, homely and comfortable. There is a large well-maintained garden at the rear of the home, and this has a purpose built bar-b-q, which the service users enjoy using for social gatherings. The staff team work hard to ensure that service users’ independence is maintained, and liaise with other professionals to maintain service users’ health and wellbeing. The home is staffed 24 hrs a day with a waking member of staff at night. Outlook Care lease the property from the Local Authority and have full maintenance and repairing responsibility. The current scale of charges are from £1,200-£1,400 per week. A statement of purpose can be obtained on request from the home and a service user guide is given to each service user when the placement commences. Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 9.30am. It took place over six hours during the morning and afternoon. Discussion took place with the registered manager and two members of care staff. The Inspector spoke to all four residents who were in the home on the day of the visit. A tour of the home was made and a number of care and staff records were looked at. The inspector found that Maplestead Road continues to improve and in so doing provide a good standard of life for service users with mental health problems. What the service does well: What has improved since the last inspection? The registered providers, Outlook Care have recently appointed a Head of Care for mental health services. He is currently reviewing all mental health services in the organisation. The home manager is confident that this review will further improve the quality of specialist mental health services within the organisation and the home. Specific mental health training is now being provided to staff in order to ensure they have the specialist skills to meet service users’ individual needs. Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have updated information, which they could rely on in making a decision to live at Maplestead Road. They are assured that their needs would be thoroughly assessed and know that the home they enter will be able to meet their needs. Service users have the benefit of a statement of terms and conditions/contract which details the obligations of the registered persons in meeting their needs. EVIDENCE: An updated statement of purpose detailing the philosophy, aims and overall services provided was in place at the home. There was evidence that service users’ needs are thoroughly assessed and this begins prior to admission to the home. A preliminary assessment is undertaken just prior to admission and during the course of their initial stay a secondary assessment of need is undertaken. The findings from these assessments feeds into a service user plan, which covers all aspects of service users’ needs and aspirations. Evidence was seen that the service users are involved in this process. As part of the admission process assessment information is also gathered from the referring agency as required by regulation. Needs are reassessed during reviews of the service user plan or as a need arises. Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 9 Each service user is given a statement of terms and conditions once there is agreement to move into Maplestead Rd. This document outlines the obligations of the registered provider as well some of the key rights of the service user. Service users sign their statement of terms and conditions, along with the registered manager and this confirms acceptance of the document by both parties. This is good practice. Evidence was seen when tracking service user files, that they are given the opportunity to visit the home and are invited for tea and dinner on separate occasions to meet the other service users. A gradual introductory process takes place whereby service users visit the home for overnight stays enabling them to have a gradual transfer into the home from their previous placement. Maplestead Road DS0000027907.V330727.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): 6,7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate systems are in place to ensure that the changing needs of service users are reflected in their individual plans. Service users are consulted and involved in decisions affecting their lives and are reassured that information held on them is handled in line with the home’s policy on confidentiality. Service users are involved in negotiating their daily routines and objectives and are encouraged to live life to their full potential subject to a risk assessment. EVIDENCE: A random sample of service user plans were assessed. Service user plans were reflective of the current needs of service users. Preliminary assessments are carried out by the manager and the care service manager following referrals received from the hospital consultants. The service user plans are reviewed monthly, three monthly and six monthly, which is carried out by the Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 11 key-worker along with the manager. This system offers support to both the staff and the service user and is useful as a way of monitoring the quality of service - user planning in the home. The hospital consultant comes to the home to review a service user’s mental health condition every three months and more often if someone’s mental health was deteriorating. This was being done on the day of the inspection. There was good evidence that service users were encouraged to make decisions about their lives and then supported to fulfill their individual aspirations, for example, attending college which has been encouraged and supported by the management and staff at the home. Appropriate risk assessments are carried out in discussion with service users and relevant specialists. These are recorded in the individual plan with action taken to minimise identified risks and hazards, enabling service users to lead independent lives. The home works well with service users by involving them and consulting them on aspects of life in the home. Regular service user meetings are carried out with minutes recorded. At this forum service users bring suggestions and contribute to life in the home e.g. where they go for their annual holidays, furnishings, menus, activities and health and safety. Service users also express their views informally and in key-worker sessions, which are also regularly held. There was evidence that the registered manager carries out service user surveys to seek the views of service users. Service user forums also take place every month with the other homes belonging to the organisation where service users are consulted about their personal care plans, attendance at mental health conferences, the development of mental health services, reviews of documents for example the service user guides, policies and procedures i.e. service users were involved in setting up the easy read procedures for bullying, advocacy, complaints, consent to treatment. A satisfactory policy on confidentiality is in place at the home at the time of the visit. Staff interviewed demonstrated a good, working knowledge on handling information held on service users. Confidential recorded information held on service users was securely stored in the home and is made available them in line with the home’s ‘Access to Information Policy’. Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 12 Maplestead Road DS0000027907.V330727.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 good. This judgement has been made using available evidence including a visit to this service. Opportunities for social and leisure pursuits and personal development are actively promoted and supported by staff for all service users to enable them to participate in the wider community in which they live. Service users are provided with varied and nutritional meals, staff promote healthy eating and individual preferences are catered for. Visitors are made to feel welcome in the home and service users are supported to maintain and establish family links and friendships. EVIDENCE: Service users have access to a wide range of leisure activities but the inspector was informed that lack of motivation is a major issue with service users agreeing to do activities and then changing their minds when it is time to go out. Hence a lot of the activities are in - house and outings to local areas for shopping. All the service users are independent choosing to carry out their own Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 14 activities. Often the service users do take the opportunity to go out individually with their families. Pictures are usually on the walls of any activities or outings that do take place. Service users spoken to were aware of their right to complain as well as their rights to good quality care. As such they sign up to their service user plans, their statement of terms and conditions and are actively involved in giving feedback on the service via service user meetings, key work sessions and service user surveys. Each service user has responsibilities for their personal space as well as making a contribution to a communal activity, which is agreed with them. As part of promoting their rights service users have access to advocacy service – made available by the organisation. Staff prepare and cook the meals with involvement from the residents and the menu for the week ahead is discussed at the weekend. However, the menu is very flexible as most of the service users change their minds on the day and are therefore offered alternatives. A range of drinks and snacks are available at all times and residents have full access to kitchen facilities. Service users can choose when and where to eat but usually eat in the large kitchen/ dining room with other residents and staff. There are no restrictions on visitors to the home and service users can receive visitors in their own rooms if they wish. All four service users have a lot of family involvement and their family are consulted regularly by the manager. Several service users also have friendships with people who live at other homes provided by the organisation. Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 15 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): 18,19,20,21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ physical and emotional health care needs are closely monitored and this ensures that service users’ needs are recognised and met. The medication policies and procedures are clear and all staff have received training, ensuring the safety of the service users. Satisfactory arrangements are in place to ensure that service users are well looked after, as they grow older. Any specific wishes they may have regarding a change in their health are recorded with an undertaking that this would be carried out as and when required. EVIDENCE: Service users receive personal support in a way they prefer, with a lot of encouragement provided to enable them to carry out their personal support tasks in a way that maintains their independence, privacy and dignity. There was evidence that service users’ needs based on assessments were recorded and they were carried out to promote their health, safety and welfare. Staff are skilled to observe changes in the general and specific health Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 16 care needs of service users and make interventions as appropriate to ensure their safety. Service users were pleased with the way in which staff provided support and care at Maplestead Road. At this visit the inspector was given an update on the person with the highest physical dependency needs. He has been given appropriate aids and is being monitored by the district nurse. Another service user is being closely monitored by a physiotherapist due to suffering from Parkinson’s disease. The ‘health files’ are being maintained to a high standard, showing good health care monitoring and a sensitive approach to supporting service users with their personal care needs. The home uses the blister pack system for medication administration. Medication is kept in a locked cabinet in the dining area, and separated for each person. None of the residents self medicate. At this visit the inspector observed service users being given their mid-day medication by a staff member. All arrangements checked were satisfactory, including the files that contain guidance on the main types of drugs being used. There is a medication hand-over sheet. Where appropriate, the date had been written on when a package was opened. The supplying pharmacist regularly visits the home to check the home’s medication supplies with an internal audit also being carried out. All staff have done a basic ‘Safe Handling of Medication’ course. Only two staff members have completed specific mental health medication training with four other staff being booked to attend this training in the next six weeks. A satisfactory policy on death and dying is in place at the home and there was a recent death in the home when the policy was implemented. The policy is satisfactory and staff showed an awareness of it. The wishes of service users regarding death are taken into account as part of their assessment process. Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and staff make every effort to sort out any problems or concerns and make sure that the service users feel confident that their complaints and concerns are listened to and will be acted upon. Staff working in the home have received training in Adult Protection/ Abuse Awareness and this ensures that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has policies and procedures for dealing with complaints and the records examined showed that all complaints, both verbal and written, are recorded with full details of investigation, any action taken and the outcome for the complainant. Two residents spoken to about what they would do if they were unhappy with anything, said that they would speak to the manager or their key worker. The registered providers - Outlook Care, have recently developed a number of core policies in a format specifically for service users. This includes a complaints policy with information about how to contact the Commission, if the complainant remains dissatisfied with the outcome of any investigation. There is a written policy and procedure for dealing with allegations of abuse and whistle blowing. All staff working in the home have received training in Adult Protection/ Abuse Awareness and are due to attend refresher training on the 28/29th March. Those staff spoken to during the inspection were aware of Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 18 the action to be taken if there were concerns about the welfare and safety of service users. A lone working risk assessment is now in place. Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 19 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): 24,25,26,27,28,29,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides a warm, safe and comfortable environment for service users, with adequate and well-maintained communal spaces. Service users bedrooms are suited to individual tastes/preferences and promote their independence. The décor, furnishings and fittings in the home are of a good standard and provide a comfortable and homely environment for the service users to live in. The home is clean and hygienic. EVIDENCE: On the day of the visit the home was clean, tidy and in good decorative order. There is an annual plan for redecoration and refurbishment and this is done routinely and in conjunction with the wishes of service users. Service users contribute to the maintenance of some aspects of the communal areas as well as their private spaces. Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 20 All residents have their own bedrooms that reflect their individual tastes. One service user showed his room which had been personalised. The house is well served for bathrooms and toilets. There is a separate toilet on the ground floor. All were found to be clean, with fresh towels and soap, and have suitable locks. A good standard of cleanliness was found in all parts of the home. In addition to service users helping with some household tasks, there is also a part-time cleaner. Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from a staff team that are committed, adequately supported and clear in their remit to providing a high standard of care to them. Hence the service users needs are appropriately met and this is a positive factor in successfully working with this group. This home has a stable, experienced and well-qualified staff team. Staffing levels are satisfactory and there are sufficient staff on duty to meet the individual needs of the service users. The procedures for the recruitment of staff are robust and provide safeguards for people living in the home. EVIDENCE: All staff have a copy of their job description and were clear on their role in providing care and support to service users. It was also clear from the interviews and informal discussions held with staff that they were motivated and committed to the service user group. The organisation provide specific training that enables staff to carry out their duties competently and with Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 22 confidence. 90 of the staff team have their NVQ level 2 qualification with other staff members waiting to start the NVQ level 2 in Care. Some other training completed by staff includes responding to voices, approaches to recovery training, medication and mental health training. The normal pattern of cover is two people on both the early and late shifts, excluding the manager. Night cover is one person doing waking nights. Staff on duty at this visit corresponded with the planned rota. The manager says this level of cover is adequate to meet the needs of the service users. The staff team is very stable, with many having experience in this setting. Outlook Care cover gaps by using staff from their other homes doing monitored extra hours through agency bookings. There has not been anyone recently recruited to the home, however, one staff member had transferred to the home from the organisation’s learning disability home and is receiving mental health training. The inspector checked a sample of staff files. These had copies of all the required documents, including a separate file of CRB certificates. There is a regular programme of individual supervision, with a forward planning programme on display. From talking to service users and assessing service user files, it was clear that the individual and collective needs of service users were met. As stated earlier in this report there were comprehensive service user plans detailing the needs of service users and they were updated, as and when necessary. These plans covered all aspects of need including social, spiritual, psychological, social, physical and healthcare needs. A good supervision system is in place to ensure that staff are supported to carry out their duties at Maplestead Road. Staff spoken to indicated that the sessions held, were both useful and regular. Supervision covers philosophy of care, care practice and training and development. This meets the minimum requirements of this standard, however staff are able to informally meet with the manager as she makes herself accessible to them. They also use the team meetings as another way gaining support. The manager and any staff who supervise colleagues should also do a supervision skills course in order to ensure that they provide effective supervision to the staff. Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 23 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): 37,38,39,40,41,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are adequate management systems in place to provide a high standard care. Service users benefit as the home is run in their best interests. Outlook Care have a systematic approach to operating their services by having up-to-date policies, procedures and accountability checks. This home’s manager works well within this structure. EVIDENCE: The manager has achieved the ‘registered managers award’, having already gained NVQ in Care at Level 4. Hence, the registered manager is qualified and competent in the way she runs the home resulting in a continually improving service. Staff described her as innovative and very supportive. Service users and staff commented that she Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 24 always makes herself available and deals with any issues to the best of her ability. There is a quality assurance system in place, which includes seeking the views of the service users through, regular house meetings and their attendance at forums such as the Mental Health Service User Forum. Service users from the home attend this forum regularly. Quality assurance surveys are undertaken and the results are published with opportunities for discussion with both staff and people using the service. The organisation’s standardised policy and procedures files are available. The registered providers, Outlook Care have recently appointed a Head of Care for mental health services. He is currently reviewing all mental health services in the organisation. The home manager is confident that this review will further improve the quality of specialist mental health services within the organisation and the home. The inspector was shown an initial sample of policies that have recently been done in an ‘Easy Read’ style as a further step in achieving service user involvement. There is a clear organisational structure that is available to staff, service users and their relatives. The service manager supervises the registered manager and this is in line with regulation. The service manager also checks the quality of care in the home through monthly Regulation 26 monitoring visits. These reports are comprehensive and a copy is sent to the Commission. From assessing the home’s records, they were found to be updated and secure with confidential files stored in locked cabinets. Records of communications are maintained in a log and service users’ plans and case records were reflective of the current situation in the home. A range of records were looked at including fire safety and accident/ incident reports. These records were detailed, up to date and accurate. Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 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 3 3 3 3 3 3 3 3 Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? 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 Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Maplestead Road DS0000027907.V330727.R01.S.doc Version 5.2 Page 28 - 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!