Inspection on 19/02/08 for Pinta

This inspection was carried out on 19th February 2008.

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

Pinta 02/02/07

Pinta 15/02/06

Pinta 24/11/05

Pinta 14/03/05

Pinta 02/08/04

Similar services:

Kestrel House, St Anne`s Opportunity Centre,

The Farmhouse

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 Pinta 548 Reading Road Winnersh Berkshire RG41 5HA Lead Inspector Kerry Kingston Unannounced Inspection 19 February 2008 10:30 th Pinta DS0000011362.V353847.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 Pinta DS0000011362.V353847.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. Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinta Address 548 Reading Road Winnersh Berkshire RG41 5HA 0118 978 3246 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) grahame.dillon@atlas.plus.com Atlas Project Team Ltd Mr Grahame Lawrence Dillon Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 2007 Brief Description of the Service: Pinta offers twenty-four hour residential care to three adult service users, of both sexes, who have learning and associated behavioural difficulties. Maidenhead and District Housing Association own the building and the care is provided by The Atlas Project Team Ltd. The house is a single storied building with all the accommodation on the ground floor. It is situated a few miles from the towns of Wokingham and Reading and there are shopping and leisure facilities within walking distance of the home. The home has its’ own vehicle and there is easy access to public transport, both trains and buses. Fees at the time of this inspection were £1871.63 per week. Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means that the people who use the service experience excellent outcomes. This is a report for the key inspection of the service, which included a routine unannounced site visit. This took place between the hours of 10.30 am and 3.00pm on the 19th February 2008. The information was collected from the Annual Quality Assurance Assessment, a document sent to the service by the Commission for Social care Inspection and completed by the registered manager of the service. There are, currently, three people resident in the home. Discussions with two staff members and the registered Manager took place. Two residents (who communicated in a limited way because of my unfamiliarity and some difficulties with communication skills) were also spoken to. Observation of practice and interactions between staff and residents was used as a further source of information throughout the visit. A tour of the home and reviewing residents’ and other records were also used to collect information on the day of the visit. What the service does well: The home makes sure that people are properly looked after by having everything about how to help them written down and looked at quite often to make sure it is still right. The home writes down how to help people stay safe but still do as much for themselves as they can. Residents are helped to do as many things as they want to so that they don’t get bored or fed up with their life. Residents go out into the local area and use all the places nearby, like the pub, the cinema and the church. This makes their life more interesting and enjoyable. The staff make sure that residents have good things to eat and that they help choose it. This makes sure that people like their food and it is good for them. Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 6 The home makes sure that people are helped to be as happy and healthy as possible by looking after them in the way that is written down and helping them to see the doctor and dentist when they need to. The staff make sure that the house is lovely and clean and it is a nice place to live in. They also listen to what people would like and try to get it in the house or garden for them. There are lots of staff to help the residents and the home will always get more staff if people want to go to special places or do special things. The home has a good manager who makes sure everything is run smoothly so that residents can enjoy their lives as much as possible. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Pinta DS0000011362.V353847.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 Pinta DS0000011362.V353847.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): 2. People who use the service experience good quality outcomes in this area. The home has all the policies and procedures in place to fully assess a prospective resident. The home would individualise the introductory programme to meet the persons’ specific needs and the needs of those already resident in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The three residents have been in the home for over ten years, there have been no new admissions. The home has an admissions policy and ensures people would have an introductory programme that would be tailor made to suit the individual. A pro forma for assessment is used to ensure that the home can meet the prospective resident’s individual needs. Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 9 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. People who use the service experience excellent quality outcomes in this area. The home has comprehensive care plans to ensure that staff support people consistently and enable them to make as many choices and decisions for themselves as possible. Detailed and robust risk assessments help staff to allow residents to be as independent as they are able, as safely as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans for all three residents were looked at. They are comprehensive and cover all areas of the residents’ life, including any equality and diversity needs. They include a communications passport, behavioural guidelines and how to provide various aspects of care to the individual. Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 10 There are detailed records kept of activities and daily living skills such as table laying, laundry, helping with meals and community participation. Care plans are reviewed monthly by means of a therapy ‘planning meeting’, this is where residents and staff review the month, an action plan is developed at this meeting for the next month and any issues identified such as a need for behavioural guidelines to be reviewed or if a health review is necessary. Formal reviews take place, at least annually, the last reviews were held in January 2008,the care manager attended. Care plans are not always correctly dated and signed as current but the manager who carries out the monthly quality assurance visit confirmed that all are up to date. Care plans detail how people make choices and how to offer them choices and encourage them to make decisions for themselves. There are communication boards throughout the home, designed to help people understand what is happening in the home, such as a ‘which staff are on duty’ board and boards in peoples’ individual bedrooms to keep them informed and involved in all aspects of their life. Daily notes confirmed that people are given choices and decision-making opportunities about their everyday life, such as choice of menus and activities. Staff were observed offering people the choice to go out to lunch and trying to encourage them to say where they would like to go. There are numerous good quality risk assessments that consider all aspects of peoples lives and ensure that they can be as independent as is safe such as making hot drinks, walking, doing laundry, cooking, attending college, participation in community activities and specific activities such as sailing and swimming. Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 11 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. People who use this service experience excellent quality outcomes in this area. The home offers residents opportunities to participate in varied and imaginative activities and works hard to find out what they really enjoy doing. People lead an interesting and rewarding lifestyle within the community. Residents are encouraged to be involved in their home life, including the provision of good quality and varied food. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents have a weekly activity plan that is ‘tailored’ to suit their individual needs and preferences. Activities for one person included, attending college to do music and dance and art classes. They also do aqua aerobics and trampolining and said that Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 12 their favourite activity is music and going to church on a Sunday to sing hymns. Another person is being carefully introduced to new activities and has been sailing and on a small plane ride to see what they enjoy the most. On the day of the visit one person was on a mid week break to celebrate their 50th birthday, this had been organised with a 2:1 staffing ratio. Activities for all residents include household chores and daily living skills. The home use an activity ‘tracker’ that shows all the activities people are offered and participate in, it is used as an assessment and monitoring tool to help staff to improve peoples motivation and participation in daily life. It is also used as an early warning system of people not liking what they are doing, losing motivation and not enjoying their lifestyle. If peoples’ participation in activities and daily life diminishes, staff look at why and what they should do about it. Residents have their preferred entertainment systems in their bedrooms and the home have provided an outside building (summerhouse) so that people can play music and one person can have their train set permanently available to them. One person agreed that they like the big screen T.V. that is provided in the sitting room as they like the programmes. Residents have two holidays a year and often more to celebrate special occasions or because it is felt to be beneficial. Daily notes showed that people are involved in the community, they use the local pubs, go to the cinema and one person goes to church regularly. People also go out for meals and use the local shops and other facilities. There was evidence that people use public transport systems and have a particular liking for train journeys, these are facilitated by staff, the home also has its’ own vehicle. Two residents and two staff confirmed that residents have plenty of things to do and there are enough staff to support them in their chosen activities. People are supported to live as respected individuals and one staff member was able to explain how they treated people with respect and dignity, with the same rights as everyone else. Staff were observed to be putting this into practice when dealing with residents. Two residents have contact with their family who regularly visit the home and participate in review meetings and other aspects of care. One resident has suffered bereavement and has no family left, they were helped through the loss of their relative by bereavement counselling, they were supported to attend the funeral and are occasionally taken to visit the grave, which is not in the local area. Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 13 Menus are balanced and nutritious, the home use only organic food and follow a health-eating regime. The food is freshly prepared and there is little use of pre-prepared or convenience food. This is to support the residents who have cholesterol problems and another who tends to gain weight. Weight charts are kept and action is taken if a problem is identified. Residents help with food purchase, choice and preparation, their participation is noted on the ‘keeping tracks’ record. Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 14 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. People who use the service experience excellent quality outcomes in this area. People’s personal, emotional and healthcare needs are well met by the staff team who take into account peoples’ choices and preferences and involve them, as much as possible, in their care. Medicines are safely administered and the home seeks the support of other agencies to ensure that it remains so. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Peoples’ preferences and choices and how they express their preferences is detailed on the care plan and in the communication passport (communication guidelines). They include risk assessments for cross gender personal care and if residents are happy with this. The only female resident has been provided with en-suite facilities. Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 15 People are involved in the care planning process, as they choose, they are encouraged to participate in all the reviews such as the monthly ‘therapy planning meeting’. Emotional needs are met by means of behaviour guidelines and seeking assistance from external ‘experts’ as appropriate. Guidelines are reviewed and amended as necessary. Staff explained how one person had recently had their guidelines amended and this resulted in an almost immediate improvement in the behaviour and well being of the individual. All residents have details of their methods of communication and communication boards to allow them to express themselves as clearly as possible. Residents were seen to be very well groomed and their dress reflected their taste, choices, age and preferences. Two of the residents indicated, clearly, that they liked living in the home. People have regular healthcare checks such as opticians, dentist and medication reviews and these are noted on their care plans. Medication and details of any medical conditions are also noted and the home keeps weight records and any other records, as necessary. The home operates a healthy eating policy using organic and fresh produce to try to ensure people stay healthy and recognise the needs of the residents who have high cholesterol. The home uses the Boots monitored dosage system. Residents show their consent for taking the medications by their behaviour and willingness to take it, all medication is orally taken and the registered manager is fully aware of the mental capacity act, which in summary form is available to all staff. Staff are very alert to any changes in behaviour or mood and this is included on the daily notes for people to monitor incase they are the result of an underlying health issue. Two of the residents have medication and one does not, the home does not use medications to help people control their behaviours and has a robust policy for the administration of ‘homely remedies’, such as paracetemol. All staff are assessed as competent by senior staff, before they are able to administer medication and receive training in the safe handling of medication. The local primary healthcare trust checks the homes’ medication systems, the last check was on the 16th January 2008 when the home had met all the standards and the pharmacist made no recommendations. Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 16 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. People who use the service experience good quality outcomes in this area. The home has a robust complaints policy and procedure that ensures residents are listened to and action is taken if there are any concerns. The home makes sure that people are protected from all forms of abuse but the role and responsibilities of outside agencies could be made clearer to the staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy and procedure, which is also produced in a resident friendly format. Staff explained that two residents would make it clear if they were unhappy or had a complaint but one would not, they were aware of how they would display unhappiness or distress, generally through their behaviour. The home has not recorded any complaints in their complaints book since the last inspection and the registered manager confirmed that they had received none. Residents were seen to be confident and happy in the presence of the staff team, one person indicated that she felt safe in the home. The organisation has a ‘protection of vulnerable adults’ (safeguarding adults) policy and procedure and the local authorities’ multi agency policy and procedures document is available in the home. Safeguarding of residents is included in the induction, during the first week but staff access the local Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 17 authorities’ training as soon as possible after appointment (the manager advised within the first month wherever possible). All staff, except one have received this training. Two staff spoken with confirmed that they had attended safeguarding training and were clear about what they should do if they suspected any abuse in the home. They were not as clear about when they should approach an outside agency although they knew that social services could be involved, if necessary. The registered manager was very clear about when to approach the local vulnerable adults’ co-ordinator and when to inform the Commission. The organisations procedure is not explicit about when to report incidents to external agencies and the registered manager gave assurance that it would be looked at when the policies are reviewed, due imminently. The Commission for Social Care Inspection has received no information with regard to complaints or safeguarding issues about this service. People have detailed ‘challenging behaviour’ guidelines that are up-dated when necessary. Restraint is not used and staff are trained in how to deal with difficult behaviours at an early stage of their employment. Peoples’ money is safely kept, the manager who conducts the monthly Quality Assurance Audit visit and the person who conducts the monthly regulation 26 visit both audit residents financial records and cash. The last check was completed in January 2008 and all was in order. The home keeps the receipts for all expenditure, and ensures peoples’ money is spent appropriately, according to the wishes of the residents. Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 18 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. People who use this service experience excellent quality outcomes in this area. The home is well kept and reflects the tastes and personalities of the residents. It is very comfortable and meets all the needs of the people who live there, improvements are made to accommodate peoples’ interests and increase their choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is very well decorated with good quality comfortable furniture and fittings. Residents have their own bedrooms and one person has an en-suite facility, to meet a gender need. The garden is very well laid out with two areas of ‘decking’. A fish pond and a large summer house, that has recently been installed to enable a resident to Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 19 have his train set erected all the time, have been added to the garden because of peoples’ interest in fish and to accommodate a ‘long time’ hobby of an individual. The additional room is also used as a music and activities room so that people have choices, with regard to location and activities they are able to participate in during their leisure time. All areas of the home reflect peoples’ taste and personality. On the day of the visit the home was extremely clean, hygienic and well kept. Residents participate in the cleaning and maintenance of the home. Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 20 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. People who use the service experience good quality outcomes in this area. The home has a well-trained and effective staff team who are knowledgeable about individuals’ needs and are able to deliver good quality care. The staffing ratios are very high and are flexible to accommodate any special or specific, long or short term, needs of the individuals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are eight staff in the home (the 9th member of staff the registered manager, works in two services), there are a minimum of two staff on duty during day time hours 7.30 am until 9.30pm and one waking night staff member. Staff are flexible and will stay after 9.30pm if there is an evening activity. Staffing levels are constantly monitored and change to accommodate activities or special occasions such as holidays where there is 2:1 staffing ratio and other specific activities, these are detailed in risk assessments. Three of the nine staff have an N.V.Q. 2 or above qualification and four staff are completing or embarking on N.V.Q.3. The organisation has internal N.V.Q. Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 21 assessors who work with an external company who provide additional assessors and verifiers. The home has a robust induction programme, which is developed to the Learning Disability Award framework. Vocational training is provided it includes autism, basic communication, makaton, epilepsy, challenging behaviour and other courses relating specifically to the needs of people within the home. Two staff spoken to confirmed that they had many opportunities to do vocational training and were encouraged to complete professional training. Staff are supervised regularly, the aim is once a month, staff meetings are held regularly and minutted. The staff meetings are resident and practice focussed, as well as covering the practical day-to-day issues, residents are invited to participate in the meetings if they wish to do so. Staff confirmed that they felt well supported and equipped to do their work. The recruitment records of the two newest staff were seen, they contained all the necessary information to ensure that people were safe to work with the residents. Advice was given with regard to the registered manager indicating on the staff records that he had seen (or indicate who had) any paperwork held at head office, such as Criminal Records Bureau checks where a number is supplied. The staff spoken to had a good understanding and knowledge of individuals’ needs. On the day of the visit staff were seen to be treating residents with respect and sensitivity and offering them choices. Residents were interacting positively and appeared to be very comfortable with them. Two residents confirmed that they liked the staff and one was able to confirm who their favourite staff member was. Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 22 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. People who use the service experience good quality outcomes in this area. The home is well managed, it works hard to ensure that it maintains the quality of the service and makes sure that people are kept as safe as is possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a registered manager, who manages two small services and has an unregistered manager who is in the home all of the time and manages any day-to-day issues. The registered manager spends half of his work hours in each of the homes. The registered manager has been in post for a number of years and is suitably qualified (Registered Managers’ Award) and experienced. Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 23 He is aware of new legislation affecting the people he works with and had a good knowledge of the mental health capacity act, new legislation is added to the staff training/induction programme as necessary. The organisation has a structured Quality Assurance System that includes monthly regulation 26 visits that are conducted by a trained administrator on behalf of the proprietor, monthly Quality Audit visits that are conducted by a registered manager on another registered managers’ service, monthly ‘therapy planning meetings’ completed by key workers with residents and an action plan that is developed each month from the results of the collected information. The registered manager advised that the system is still developing and is to include an annual report and an annual development plan written from the information collected during the previous year. There was a discussion about reviewing how residents’ contributions to this process are recorded and how to gather information from interested other parties, questionnaires were used but with very limited useful feedback. The Annual Quality Assurance Assessment received by the Commission noted that all Health and Safety maintenance checks had been completed and a sample seen on the day confirmed the dates of some of these. The manager advised that policies and procedures in all areas are due for review and some up dating is necessary. The home has methods of recording incident and accidents and use recognised systems of analysing any behavioural incidents that may occur. There have been no accidents and two incidents since the last inspection, advice was given about the use of body charts. All staff have received the necessary Health and Safety training which is updated as necessary. Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 24 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 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 3 X X 3 X Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 25 NONE 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 Pinta DS0000011362.V353847.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Close Hermitage Lane Maidstone, Kent ME16 9NT 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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