Inspection on 26/04/07 for Misty Falls

This inspection was carried out on 26th April 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

Misty Falls 09/02/06

Misty Falls 06/09/05

Misty Falls 22/02/05

Misty Falls 12/10/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Misty Falls 22 Pendarves Road Penzance Cornwall TR18 2AJ Lead Inspector Diana Penrose Key Unannounced Inspection 26th April 2007 01:30 Misty Falls DS0000009078.V337055.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 Misty Falls DS0000009078.V337055.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. Misty Falls DS0000009078.V337055.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Misty Falls Address 22 Pendarves Road Penzance Cornwall TR18 2AJ 01736 360042 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) Mrs Shirley Maxine Hoblyn Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Misty Falls DS0000009078.V337055.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home may accommodate the present two named service users beyond the age of 65 years. 9th February 2006 Date of last inspection Brief Description of the Service: Misty Falls, 22 Pendarves Road, Penzance, is a small care home providing accommodation and personal care for up to two adults with a learning disability. The Registered provider lives on site with her family and provides all the necessary care and support to residents with the assistance of two parttime assistants. The home is situated in Penzance within easy reach of transport routes, shops and local community facilities. Accommodation is provided in a mid-terrace, two storey house that is spacious, well decorated and domestic in character. Residents have their own bedrooms and share a bathroom on the first floor. They have the exclusive use of a lounge/ dining room downstairs, are able to access the large, well-equipped kitchen and have use of a well-maintained rear garden. The home is clean, tidy, well furbished and maintained throughout. The residents currently living in the home go to work and attend weekday activities. The residents are given ample opportunities for socialising and visitors are openly encouraged. Information about the home is available in the form of a statement of purpose / residents’ guide, which can be supplied to enquirers on request. A copy of the most recent inspection report is available in the home. Fees are £331.83 per week; this information was supplied to the Commission during the inspection. Residents pay for any private healthcare provision, hairdressing or personal items such as confectionary and toiletries. Misty Falls DS0000009078.V337055.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An Inspector visited Misty Falls Care Home on the 26 April 2007 and spent three and a quarter hours at the home. This was a key inspection and an unannounced visit. The purpose of the inspection was to ensure that residents’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus was on ensuring that residents’ placements in the home result in good outcomes for them. All of the key standards were inspected. On the day of inspection two residents were living in the home. The methods used to undertake the inspection were to meet with the residents and the registered provider to gain their views on the services offered by the home. Records, policies and procedures were examined and the inspector toured the building. This report summarises the findings of this inspection. The registered provider has complied with the one recommendation made at the last inspection. Residents expressed a high satisfaction with the care and services provided at the home and said they are treated with kindness and respect. Overall the home is providing an excellent quality of care to the residents placed there. What the service does well: The registered provider maintains a very well run home that is centred on the residents. Both residents have lived with the family for many years and they said they are very happy in the home; one said, “It is my home”. The home is well maintained, warm, clean and comfortable. The residents have some facilities that are separate to the family so they can have privacy. The residents are encouraged to be as independent as possible and live their lives as they choose. Any risk elements are assessed and documented. Both residents are independent and go out into the community to work and to socialise. They have an annual holiday and visit their family when they wish. Friends and family are also very welcome to visit the home and the residents can contact them by telephone. Each resident has an individual care plan that is very detailed; it is reviewed every six months with the resident and a social worker then the family are given a copy to review. The plans are signed by the resident, their representative and a social worker. Relevant risk assessments are included with the care plan and reviewed regularly. A healthy diet is encouraged and residents have plenty of choice in what they eat. As they also eat at work or at clubs this is taken into consideration when preparing meals in the home. Fresh vegetables and fruit are provided daily. Misty Falls DS0000009078.V337055.R01.S.doc Version 5.2 Page 6 Residents require minimal support with personal care and this is documented. The registered provider is the main carer supported by a part time care assistant and a housekeeper who work minimal hours each week. The healthcare needs of the residents are met and they have access to a doctor and other health professionals as required. Both residents spoke highly of the registered provider and said they are well looked after by the kind and caring staff. The new member of staff appears to have settled in extremely well. There have been no complaints made to the home or the Commission and all staff have received training regarding the protection of vulnerable adults. The residents have information on how to complain and people they can contact if they need to. One resident showed the inspector a variety of leaflets from the department of adult social care that he had found interesting. Residents meetings are held regularly with the staff; the registered provider’s family have more recently been included. Quality assurance questionnaires are completed with the residents annually and these have been positive. The residents are actively encouraged to air their views at all times and they both spoke very openly about the home and the way they live. What has improved since the last inspection? What they could do better: There were no requirements made at this inspection but a few issues were discussed with the registered provider. The registered provider is going to contact the department of adult social care to obtain up to date contracts of residency for the residents. The registered provider said she is going to expand the medicines policy to better inform the staff, although her policy is already Misty Falls DS0000009078.V337055.R01.S.doc Version 5.2 Page 7 used in conjunction with the the royal pharmaceutical guidelines for care homes. The registered provider said she is reviewing and expanding the recruitment policy as it is due for a review. 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. Misty Falls DS0000009078.V337055.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 Misty Falls DS0000009078.V337055.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents will only be admitted to the home following an assessment of their needs to ensure the home can provide adequate care. EVIDENCE: Evidence was provided in the form of documentation and talking with the registered provider. There have been no new admissions to the home for seven years. The registered provider said she would not accept anyone without a full Social Services assessment. She would also invite the prospective resident for a meal and then to stay overnight or for a weekend so that she could do her own assessment. The present resident’s assessments are reviewed along with their care plans every six months. The registered provider said she was going to contact the department of adult social care regarding up to date contracts for the residents as they only have financial contracts on file. The home’s terms and conditions of residency are included in the resident’s guide. Misty Falls DS0000009078.V337055.R01.S.doc Version 5.2 Page 10 Misty Falls DS0000009078.V337055.R01.S.doc Version 5.2 Page 11 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 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Individual care plans are generated for each resident that are informative as to their needs and are reviewed regularly with the resident, family and social worker. Residents make decisions about their lives; assistance and support is given where necessary. Risks are assessed and appropriate support is given enabling residents to lead an independent lifestyle. EVIDENCE: Evidence was provided in the form of documentation, records, case tracking, interviews with residents, staff and registered provider. Misty Falls DS0000009078.V337055.R01.S.doc Version 5.2 Page 12 Each resident has an individual care plan that is drawn up by the registered provider with the resident and a social worker. A copy is sent to their family representative for approval and all parties sign the document. The care plans are reviewed every six months. Relevant risk assessments are undertaken. Daily records are maintained in separate diaries for each resident. The registered provider said residents are assisted to make decisions about their lives and the residents said this was true. One resident said he goes out and does what he wants as long as he tells the registered provider where he is going. There was a list of his activities that shows he goes out a great deal and attends various clubs. Residents are encouraged to manage their own finances within their capabilities; one resident showed the inspector how he manages his money and the records that are maintained. Both have bank accounts and lockable storage space is provided. The registered provider is appointee for one resident and maintains suitable accounts. House meetings enable residents to make decisions and there is evidence in the daily records. Both residents said there is a choice of food and the routines of daily living are flexible. Residents are encouraged to take responsible risks and there are very good written risk assessments with the care plans. The registered provider explained that issues involving a higher risk are regularly discussed with the residents, their representatives and maybe external professionals - examples were given. The epilepsy nurse has written risk assessments for both residents. The home has written procedures in respect of the action to be taken in the event of a resident going missing from the home. Misty Falls DS0000009078.V337055.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): 12, 13, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents take part in appropriate activities and are assisted with training and education to encourage their independence and individuality if they wish. Links with the local community are excellent and allow residents the opportunity to socialise. Residents have good contact with family and friends; they are supported to develop relationships according to their wishes. Residents participate with household tasks according to their individual risk assessment, their rights and individual choices and preferences are respected. Dietary needs of residents are well catered for with a varied selection of food available to meet their taste and preference. EVIDENCE: Evidence was provided in the form of documentation, records, observation, talking with residents and the registered provider. Misty Falls DS0000009078.V337055.R01.S.doc Version 5.2 Page 14 Residents are encouraged to continue their education, undertake training and join in activities as they wish. They attend day centres and progress reports are issued. One resident attends link to learning to improve his maths and English skills. Both residents are actively involved in a range of activities and attend various clubs. Information on activities, advocacy, holiday options and local facilities is provided. One resident is engaged in local church activities and talked about these. Both residents attend weekly activities in the community. One resident goes to organised cycling sessions when there is a person to assist him. Both residents go on an organised annual holiday and they spoke about this as they are going in May 2007. One resident is hoping to go to Paignton for a weekend as well. Both residents go out to work during the week. The registered provider said that both residents are independent, they assist in the household tasks and they go into town and out walking at the weekends, for example. Residents are encouraged to maximise their independence and make use of local community resources in accordance with their individual care plan; both residents said they enjoy a social life that meets their needs. They are provided with ample information on local resources in a box file in their dining / sitting room and on a notice -board in the kitchen. The registered provider supplies transport but they also use public transport. Arrangements for residents to be accompanied on activities outside of the home are available, where necessary. Both residents go out to work although one is now semiretired. Misty Falls DS0000009078.V337055.R01.S.doc Version 5.2 Page 15 Residents have photographs of family and friends in their rooms. The registered provider said that both residents had regular contact with their families by visits or telephone. Both residents talked about this. One said he sees his father and brother every weekend another talked about going out with his friend. There is a record of all visitors to the home. The daily routines promote independence and are flexible within reason, more so at the weekends. The daily routines and house rules are included in the care plans. Both residents have front door keys and are able to enter and leave the home as they wish. Neither resident wants a key to their room. Both have mobile phones for contact when they go out. The registered provider said that residents open their own mail and are addressed by their preferred name. A healthy diet is encouraged and the home has a very flexible menu plan. Residents are provided with a cooked evening meal and are able to access fresh fruit and snacks at all times. They have lunch at their work or day centres during the week and meal times are more flexible at the weekend. Residents have their meals in their own lounge / dining room. A special meal and a cake are provided on birthdays and friends are invited for tea if they wish. Records of meals served in the home are kept Misty Falls DS0000009078.V337055.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is given to residents according to their needs, ensuring their individual preference is respected. Residents have access to health care services as necessary to ensure their physical and emotional needs are met. There is a suitable system and policy in place for dealing with resident’s medicines that assures their safety. EVIDENCE: Evidence was provided in the form of documentation, records, observation, talking with residents and the registered provider. The registered provider said she ensures that appropriate support, care and encouragement are provided. Both residents said they are happy with the care provided and that their privacy is respected. They spoke highly of the staff and said they do not need much assistance. Specialist health care workers are consulted as necessary. The arrangements for the provision of personal and healthcare support are stated in the home’s statement of purpose and residents’ guide and are detailed in residents’ care plans. Misty Falls DS0000009078.V337055.R01.S.doc Version 5.2 Page 17 Both residents are registered with a GP and specialist health care workers are consulted as necessary, for example the epilepsy nurse, dentists and opticians. A healthy diet is provided and residents weight is monitored. The royal pharmaceutical guidelines for care homes forms part of the home’s medicine policy. The registered provider said she is going to expand the medicines policy to provide more direction for the staff. Medicines are stored securely in a locked cabinet. A monitored dose system is in use and appropriate records are maintained. The registered provider has tried to obtain new medicine administration record charts from the pharmacist without success. Patient information leaflets are kept. The registered provider and her staff have undertaken appropriate medications training. Misty Falls DS0000009078.V337055.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a suitable complaints procedure that ensures complaints will be listened to and acted upon. Arrangements are in place for the protection of residents including relevant staff training, safeguarding resident from harm or abuse. EVIDENCE: Evidence was provided in the form of documentation, observation and talking to the registered provider There is a suitable complaints procedure in place that is available to the residents and their relatives. The residents were relaxed in the home and aired their views openly. There have been no complaints to the home or the Commission. Several but several letters of thanks and appreciation have been received from relatives. The home has a written adult protection and whistle-blowing policy. There are also various leaflets on abuse and an Adult Protection training video. The registered provider and the staff have attended the ‘No Secrets’ training and there is a copy of the local inter agency procedures available. There is a safe system for the management of resident’s money. Records are maintained of each transaction and receipts for expenditure are kept. The registered provider is appointee for one resident. Each resident has a lockable cash tin for the storage of money. Misty Falls DS0000009078.V337055.R01.S.doc Version 5.2 Page 19 Misty Falls DS0000009078.V337055.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home and grounds are well maintained providing a safe environment for residents, staff and visitors. The home is clean and free from offensive odours making it a pleasant place to live in. EVIDENCE: Evidence was provided in the form of a tour of the building, observation, talking with residents and the registered provider. Misty Falls DS0000009078.V337055.R01.S.doc Version 5.2 Page 21 There have been no changes to the layout of the home since the last inspection. The home provides a comfortable, homely environment that is clean and tidy with no offensive odours. The grounds are tidy and attractive and they are accessible to the present residents. The home is not accessible to wheel chair users. One resident helps with the gardening. There is adequate heating, lighting and ventilation. The home is well maintained and there is a programme for re-decoration and refurbishment. New windows have recently been installed that have reduced the heating demand for the home and the external noise levels. There is a new stainless steel sink unit ready for installation in the kitchen. The laundry facilities are adequate for the size of the home and are situated in an outside building at the back of the home. This building has been re-vamped to include a games room; there is a pool table, darts and a punch bag. Protective clothing is provided for staff for infection control. Misty Falls DS0000009078.V337055.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 and 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported by experienced, qualified staff who are kind and caring and resident’s say they meet their needs. Recruitment procedures undertaken by the Registered Manager are robust and offer protection to the residents. Staff receive training relevant to their roles to ensure that residents needs are met appropriately. EVIDENCE: Evidence was provided in the form of documentation, records, observation, talking with residents and the registered provider. The residents live as part of the family with the registered provider as the main carer. There is a new part-time care assistant (6 hours per week) and a part time housekeeper (4hours per week) employed. Their roles are mainly house sitting and supervision of residents. The registered provider said the new member has both NVQ level 2 and 3 in care. Both members of staff are experienced and the housekeeper has worked at this home for 12 years. Misty Falls DS0000009078.V337055.R01.S.doc Version 5.2 Page 23 The registered provider said she is reviewing and expanding the recruitment policy. The documents required by legislation are on file, the registered provider is awaiting copies of the new employee’s training certificates. Both employees have been issued with a relevant job description that defines their role. The registered provider has also provided them with a list of typical duties to be undertaken on a shift. Both staff have terms and conditions of employment and a 6 monthly appraisal is undertaken with the registered provider. The new employee has undertaken a suitable induction programme and the registered provider said she has settled in well at the home. Both residents said they get on well with the staff, they said they are kind and look after them well. The residents are very independent and require minimal personal assistance. Misty Falls DS0000009078.V337055.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 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager is very competent and experienced and residents benefit from a really well run home. The home is run in the best interest of the residents and they benefit from the Quality Assurance systems in place. The registered provider promotes the safety of the residents and appropriate checks are undertaken to ensure the health, safety and welfare of residents and visitors to the home. EVIDENCE: Evidence was provided in the form of documentation, records, observation, talking with residents and the registered provider. Misty Falls DS0000009078.V337055.R01.S.doc Version 5.2 Page 25 The registered provider is competent and experienced to run the home. She has achieved the Registered Managers’ Award and said she keeps up to date by attending relevant study days and reading care publications. She said that she is attending person centred planning training in June along with the care assistant. The registered provider has a very good rapport with the residents and they interact well with her. Residents said the registered provider looks after them and runs the home very well. The registered provider has developed a suitable quality monitoring system for the home and survey results are positive. The resident’s are assisted to complete the surveys with the staff. The registered provider said she has regular contact with the resident’s relatives and their comments are welcomed. Residents meetings take place regularly and the registered provider’s children have been included in these. No formal staff meetings take place but appraisals take place every 6 months. There are environmental risk assessments for the home. The registered provider is awaiting a form for updating the fire risk assessment from the fire officer. Fire drills take place every 6 months and residents are aware of the fire procedure. The registered provider and staff attend formal fire training twice a year. Hazardous substances are stored safely and data sheets are available for COSHH purposes. There have been no accidents in the home. The registered provider and staff have achieved the Basic Food Hygiene Certificate and have attended a first aid course. All service checks are up to date and the electrical wiring test recommended at the last inspection has been completed. Misty Falls DS0000009078.V337055.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 X 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 4 33 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 4 X 3 X X 4 X Misty Falls DS0000009078.V337055.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. 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 Misty Falls DS0000009078.V337055.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP 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 Misty Falls DS0000009078.V337055.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!