Inspection on 29/11/05 for Popis Gardens (1 & 2)

This inspection was carried out on 29th November 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Popis Gardens (1 & 2) 16/03/09

Popis Gardens (1 & 2) 26/03/07

Popis Gardens (1 & 2) 10/05/05

Popis Gardens (1 & 2) 27/11/04

Popis Gardens (1 & 2) 21/06/04

Popis Gardens (1 & 2) 15/01/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Popis Gardens (1 & 2) King George Road Ware Hertfordshire SG12 7DU Lead Inspector Tom Cooper Unannounced Inspection 29th November 2005 12:45 Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 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 Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 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. Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Popis Gardens (1 & 2) Address King George Road Ware Hertfordshire SG12 7DU 01920 485 030 01920 462732 popes@grantahousing.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) Granta Housing Society Limited Ilse Maria Sharp Care Home 10 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (10), Physical disability (10), of places Physical disability over 65 years of age (10) Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 2005 Brief Description of the Service: 1 and 2 Popis Gardens is a care home first opened in 1993 providing personal care and accommodation for ten adults with learning disabilities, who may also be over 65 years of age and have physical disabilities. The home is owned and operated by the Granta Housing Society, a voluntary organisation. The home is located in a residential neighbourhood in Ware, within easy reach of the shops, pubs and other community facilities of the town. The premises comprise two separate purpose-built bungalows standing in their own cul-desac off King George Road. Each bungalow has five service users’ bedrooms and fully self-contained domestic facilities including a lounge, dining room, large kitchen, laundry room and ample bathroom and toilet facilities. Both bungalows are fully wheelchair-accessible and have accessible gardens. Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection for the current inspection year and took place on a weekday afternoon and evening. The main focus of the inspection was to check compliance with the statutory requirements and any action taken in respect of the recommendations made at the last inspection as well as monitoring the well being of the service users. Discussions were held with the registered manager, an assistant manager, three other members of staff on duty and the service users in residence. Documentation checked included a sample of service users’ care plans, and records of accidents and incidents, fridge/freezer temperature records, medication records, the complaints procedure, minutes of residents’ meetings, personnel records and staff training records. A tour was made of both bungalows. The inspection indicated that the new manager and senior staff team had worked well together and made good progress in addressing the issues identified at the last inspection, while maintaining the caring ethos of the home. The service users appeared content and obviously enjoyed good relationships with staff. What the service does well: Service users looked well cared for and seemed happy in the home. Those who expressed their views were all positive and the non-verbal residents appeared relaxed and content. Staff were very knowledgeable of individual needs and skilled in supporting them to express their views and make choices, as well as monitoring their status and interpreting their wishes. Comprehensive details of individual needs and the actions taken to meet them were noted in care plans, although staff were in the process of introducing revised documentation designed to produce more “person-centred” care plans and this meant that some were only partly completed in the new format. Both bungalows are spacious, airy and well maintained, with a high standard of domestic style décor. The communal rooms are large and accessible and have modern televisions and other entertainment equipment. The kitchens are attractive and hygienic and suitably equipped. Service users’ bedrooms are highly individual and personalised to suit the tastes and interests of the various residents. Special equipment such as assisted baths and hoists is provided as required and serviced regularly. Heating and lighting are adequate. The semienclosed site is relatively private whilst remaining part of the local community. and affords a good degree of safety. No health and safety hazards were noted on touring the premises. The manager and two assistant managers have now been in post for some months and have forged an effective working relationship that has strengthened the senior team and produced more consistency in the delivery Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 Page 6 of care. Staffing levels by day and night are considered adequate to meet the needs of the current service users. Granta operates a thorough quality assurance system involving annual canvassing of the views of residents and their relatives on different topics. What has improved since the last inspection? What they could do better: Care plans produced in the revised format should contain clear evidence of the involvement of the service user or his or her representative and a record of regular reviews and updates. The manager and staff must ensure that the recording of the administration of medication to service users is always recorded on the MAR sheets. Several gaps were found on MAR sheets checked in one of the bungalows. A requirement has been made in this report. Granta remains appointee for all the residents’ benefits. Residents have no choice about how their money is spent because their personal allowances are spent on their behalf on clothing, toiletries, activities and holidays. They also have to pay for the expenses of staff accompanying them on activities and holidays. DLA mobility allowance is used to fund the home’s two minibuses. The problem with this is that it compromises individual choice and there is no evidence that residents have agreed to these financial arrangements. This is regarded as paternalistic practice and therefore the recommendation made in successive inspection reports has been reiterated. Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 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 Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 Information about the philosophy of care and operation of the home including the procedures in place to meet individual needs is available to prospective service users and their relatives. Assessments are carried out to ensure that the home would be suitable and staff have the relevant information on any prospective service user’s needs and aspirations prior to admission. Before deciding on admission, prospective service users have the opportunity to visit the home to experience the atmosphere and evaluate the care services on offer. EVIDENCE: The home has a statement of purpose and service user’s guide that contain the required information to facilitate informed decision making about the home. These were updated during 2005 to reflect the management changes that occurred and improve service user accessibility. No new residents had been admitted since the last inspection. However the admissions procedure stipulates that a full needs assessment must be made prior to any admission and this was on file in respect of the most recently admitted person. Any new resident would be admitted subject to a trial period, at the end of which a review would be convened, attended by all involved parties and the placement confirmed or the trial period extended if appropriate. Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Service users’ individual needs and comprehensive risk assessments are detailed in their care plans. These documents enable staff to provide the care required to a consistent standard. However care plans do not reflect service users’ involvement. Staff support service users to make decisions for themselves and genuine choices about their lives, including participating in residents’ meetings. Service users are supported to take responsibly assessed risks in order to maximise their opportunities for stimulation and independence. EVIDENCE: Care plans sampled contained detailed assessments of individual needs coupled with clear instructions on how to proceed to meet them. Areas covered included personal care, emotional and social needs, with each need separately identified and care action plans set out with risk assessments and risk management strategies attached. The manager and staff have been working on a revised care plan format designed to produce more “person-centred” plans. The examples seen had been partially completed in this style. However there was little evidence of the formal involvement of the service user in the Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 Page 11 process. The manager felt it would be difficult to achieve this for those service users with little or no verbal communication skills. In such cases a representative from outside the home should be asked to contribute to the process and endorse the suitability of the care plan to provide the evidence to meet the standard. As found at previous inspections, each resident has a bank account but their benefits, including the Disability Living Allowance (DLA), are paid direct to Granta. The personal allowance component of benefits is used to pay for residents’ clothing, toiletries, activities and holidays and the DLA is used to fund the home’s two minibuses. This is a longstanding historical arrangement but there is no evidence that individual service users have agreed to it and no account of how the money is used for their benefit. The proprietor has previously stated that an agreement is in place with Hertfordshire County Council Adult Services Department that residents’ DLA may be used to provide transport but there is no documentary evidence of this. This practice is considered paternalistic and undermines the principles of maximising independence and choice and for this reason the recommendation made in previous inspection reports has been reiterated. Residents’ meetings are held periodically, with minutes taken and decisions recorded. Minutes seen showed that the able residents take turns to chair the meetings. Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Service users are encouraged to decide for themselves the activities they wish to take part in. They are involved in a wide range of suitable activities that provide variety of experience, stimulation and the development of independence skills. Family contacts, personal relationships and community involvement are encouraged and facilitated so that service users can lead fulfilling lives. Individual rights and responsibilities are recognised and respected. Service users are provided with a healthy diet, adjusted as necessary to cater for particular requirements. Mealtimes are friendly social occasions. EVIDENCE: Care plans note the activities planned for each resident. Residents follow their own choices and participate individually or in groups as appropriate. Some residents asked said they were satisfied with their current programmes and enjoyed the lifestyle available to them in the home. Most residents attend a day centre and benefit greatly from contact with the Guideposts Trust who organise activities in the local community and take each individual out for three half days per week. Typical activities include going to the cinema, shopping, bowling, going to the pub and so on. Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 Page 13 Residents decide on and plan their own holidays and choose the people they wish to go with. As indicated earlier in this report their personal allowances are used to pay for activities, outings and holidays (although Granta contributes to part of the cost of holidays) and they are also obliged to pay for the expenses of the staff who accompany them. In previous airings of this issue Granta has stated that they have raised the suggestion of funding for holidays with the commissioning authority but the response was unfavourable, therefore the residents continue to have to pay for staff expenses. The result is that they have minimal control over how to spend their money as most of it is spent on their behalf. This is considered a restrictive practice, especially as some of the residents are clearly capable of making informed decisions for themselves. Staff support service users to maintain family contacts and enjoy positive relationships with others inside and outside the home. They also assist them to be as independent as possible. For example, daily living activities are noted in the care plans as goals to be achieved. Depending on their abilities and to some extent willingness to participate, service users assist staff with household tasks such as shopping and cooking. Menus are planned weekly by the service users in conjunction with the staff, and a well balanced, nutritious diet is provided. Any special dietary requirements are noted and catered for appropriately. For example, one service user has diabetes and staff monitor her diet very closely by reference to specific dietary goals listed in her care plan. There is a daily menu book containing pictures of favourite foods and meals to help the service users make their choices. Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Staff care for the service users with sensitivity and respect and constantly monitor their condition. Service users’ health is monitored and potential problems identified and dealt with. Comprehensive records of health care needs are included in care plans. The home operates sound medication procedures that protect service users’ interests. However care must be taken to ensure accurate recording of administration. EVIDENCE: Comprehensive details of service users’ personal and healthcare needs are recorded in care plans. Staff are very vigilant regarding the daily welfare and physical condition of individual residents and refer medical problems to health professional s as appropriate. One resident has complex health needs and frequent hospital appointments that are arranged by staff. Full details are recorded. During the inspection the staff on duty were noted to be working with service users in a calm and respectful way and deployed various strategies in relation to individuals as indicated in their care plans. The medication system in one bungalow was checked. The monitored dosage blister pack system is used. Sound procedures for the receipt, storage, Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 Page 15 handling and recording of medicines brought into the home were in place. Unfortunately several signature gaps were noted over a three week period on the medication administration record (MAR) sheets with no explanation of the apparent non-compliance with the GP’s prescription. All the relevant pills were missing from the blister packs therefore the missing signatures were probably an oversight. Nevertheless, all administration/movements of medication must be recorded. Also, the dates of opening had not been recorded on packets and bottles of medication not in the blister packs. This should be done to aid monitoring of amounts retained and reconciliation against the MAR sheets. Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Service users have ready access to the complaints procedure and many know how to make a complaint. Staff encourage and help service users to make their concerns known. Staff training in the protection of vulnerable adults is ongoing and this ensures that service users are protected from abuse. EVIDENCE: The home has an adequate complaints procedure that explains in simple language how to make a complaint. The name and address of the CSCI is included in the document for the referral of a complaint if desired. Most of the residents cannot read, so staff have explained the procedure to them and the manager plans to discuss the issue from time to time in residents’ meetings. A tape-recorded version of the procedure is also to be produced for residents to hear. One resident asked had a clear idea of how she would go about making a complaint should she wish to do so. No formal complaints had been received since the last inspection. Staff said they constantly asked residents for their views on the operation of the home and tried to resolve any grumbles at an early stage. POVA training certificates were seen in three staff files and the manager estimated that half the team had received adult protection training. The manager had a good understanding of the relevant procedures and a copy of the Hertfordshire inter-agency adult protection guide was being kept in the office. Staff understand their responsibilities under the home’s whistle blowing policy when responding to allegations or suspicions of abuse or neglect. Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 The bungalows are well designed to suit people with physical disabilities, are well maintained, suitably furnished and equipped to provide a safe, comfortable and homely environment for the service users. The bungalows are spacious with large bedrooms and communal areas. Specialist equipment is provided to assist staff in meeting service users’ moving and handling needs. Staff maintain a good standard of cleanliness and hygiene. EVIDENCE: The home was purpose-built with wide corridors and doorways to facilitate the mobility of service users with physical disabilities. Both bungalows are well maintained and decorated in domestic styles and were found to be clean and tidy and free from unpleasant smells. Service users have their own bedrooms, which are spacious and very personalised to reflect individual interests and tastes. Much of the flooring is cushioned vinyl or laminate in attractive patterns or wood effect, although the corridor and living room carpeting in Bungalow 1 has become rather worn and Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 Page 18 stained and should be replaced soon. The living rooms, dining rooms and kitchens are large and modern and provide impressive communal spaces. New cookers had been purchased for both houses the day before the inspection, which staff said would make cooking much easier. Specialist equipment such as assisted baths and hoists are provided as necessary and records showed they had been serviced within the last year. Heating, ventilation and lighting are adequate. The heating system plumbing in Bungalow 2 was replaced in 2005 and Granta is assessing the state of that in Bungalow 1. Laundry facilities are clean and well organised, with ample capacity in each bungalow to cope with the workload generated by five residents. Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 36 Adequate staffing levels are provided to meet service users’ needs. The home employs experienced support workers who have access to regular relevant training that equips them to support and care for service users’ changing needs. All staff are also regularly supervised by senior colleagues. Therefore service users are supported by an effective staff team. The home has rigorous recruitment procedures that ensure staff are fit to work at the home and protect service users’ interests. EVIDENCE: Staff rotas show that two staff are on duty in each bungalow during the day shifts from 7.30 am to 10.00 pm. Night staffing is by one person awake and one sleeping in. These levels are adequate to meet the needs of the current group of residents. The manager and other staff said that Granta provides excellent access to relevant training and numerous certificates were noted in the personnel files, including topics such as adult protection, moving and handling, infection control, disengagement techniques and so on. This commendable commitment to training builds on the knowledge and skill base that staff already have. One new member of staff had completed a three week induction programme, which included a week of formal training at Granta head office. Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 Page 20 Staff benefit from regular one to one supervision with senior colleagues. Staff spoken with said that they felt well supported and rated teamwork in the home as good. The manager explained that for practical reasons she had abandoned the plan referred to in the last inspection report to roster staff to work across both bungalows but had now arranged for individual staff to work in both houses at least some of the time to ensure they were familiar with both sets of residents and improve team cooperation. Four personnel files were examined to check that the information and documents required by regulation had been obtained, in compliance with a previously outstanding requirement. All the files were complete, with two references, identity evidence, CRB disclosures and photographs of the members of staff. Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 42 The home is well managed, with a strong and effective senior team in place, ensuring that the needs of the service users are met and the home meets its aims and objectives. The manger has a clear sense of purpose and commitment to high care standards and provides strong leadership to produce consistent care delivery to the benefit of service users. The home is a safe place to live, with risk assessments in place and equipment maintained and serviced regularly. EVIDENCE: The manager has long relevant experience in social care, having been assistant manager at another Granta home before being appointed to Popis Gardens. She has been in post since April 2005 and has been joined by new assistant managers in each bungalow. Together they have worked with staff towards improving consistency and communications in the team. The manager has a clear sense of direction and is prepared to offer firm guidance to ensure that standards are maintained. She is also prepared to advocate strongly on behalf of individual residents when dealing with outside health professionals, for Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 Page 22 example in respect of the care management of one resident with diabetes who requires attention from the community nursing service. Staff spoken with said they felt the manager provided effective leadership and was approachable. She related very well to residents, some of whom obviously enjoyed spending time with her. Staff mandatory training was ongoing. Training in fire safety, moving and handling, food hygiene and infection control are covered during the induction of new staff. Both bungalows were toured and no health and safety hazards were noted. Fire extinguishers, hoists and assisted baths had been serviced within the last year. Hot water delivery was regulated within safe limits. The accident records were checked and found to be properly recorded with details of any follow up action taken noted. Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X 3 x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Popis Gardens (1 & 2) Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 X X X 3 X DS0000019498.V265201.R01.S.doc Version 5.0 Page 24 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. 1. Standard YA20 Regulation 17(1)(a) Sch 3 Requirement All medication administered to service users must be signed for on the MAR sheets. Timescale for action 29/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA7 Good Practice Recommendations Care plans should reflect and record the involvement of the service users or their representatives and should be regularly reviewed. Residents should be able to decide how to use their own personal allowances and DLA mobility benefit. Residents should pay only for their own costs for holidays and activities and not for the staff that accompany them [This recommendation has been repeated in successive inspection reports]. Dates of opening should be recorded on bottles and packets of medication not held in the blister packs. Worn carpeting in Bungalow 1 should be replaced. 3. 4. YA20 YA24 Popis Gardens (1 & 2) DS0000019498.V265201.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 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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