Inspection on 31/10/07 for St Michael's

This inspection was carried out on 31st October 2007.

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

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

Other inspections for this house

St Michael's 13/10/09

St Michael's 31/07/09

St Michael's 19/06/09

St Michael's 20/04/09

St Michael's 15/12/06

St Michael's 14/02/06

St Michael's 14/06/05

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

CARE HOME ADULTS 18-65 Priory Gate 129-131 Wingfield Road Stoke Plymouth Devon PL3 4ER Lead Inspector Antonia Reynolds Unannounced Inspection 31 October 2007 1:30 st Priory Gate DS0000062825.V349776.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 Priory Gate DS0000062825.V349776.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. Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Priory Gate Address 129-131 Wingfield Road Stoke Plymouth Devon PL3 4ER 01752 564944 01752 563400 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) www.healthcare-trust.com Stoke HealthCare Ltd Mr Anthony Paul Hanwell Care Home 37 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (37) of places Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only- Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Mental disorder, excluding learning disability or dementia- Code MD The maximum number of service users who can be accommodated is 37. 15th December 2006 Date of last inspection Brief Description of the Service: Priory Gate is a care home providing personal care and accommodation for thirty-seven people, aged 18 - 65, with mental health needs. At the time of inspection, the home was undergoing a major refurbishment and there were only fifteen service users resident in one half of the home. Therefore this description only applies to half of the home, as the other half is unoccupied and inaccessible to service users. The home is privately owned by Stoke Healthcare Ltd and the directors also own other care homes in the South West of England. The fee levels start at approximately £1000 per week and vary depending on the individual needs of service users. Information about the home and copies of inspection reports can be obtained from the Registered Manager, Tony Hanwell. The home was purchased by the present owners in March 2005. It consists of a large detached three-storey building situated in its own grounds and close to Stoke village in Plymouth. It is within walking distance of local shops and amenities, central Plymouth is accessible by public transport, and the home has its own car. All sixteen bedrooms are single and located on each floor. Five of these have en suite showers and toilets. Bathing/showering and toilet facilities are available on each floor, close to the bedrooms and communal rooms. There are large lounge and dining rooms on the ground floor. Attached to the dining room is a conservatory, where service users may smoke if they wish to. The home is wheelchair accessible on the ground floor only. Parking space is available inside the grounds and on the street outside the house. Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection consisted of an unannounced visit between 1.30pm and 5pm on Wednesday, 31st October 2007 and 10am and 12.30pm on Thursday, 1st November 2007. The Registered Manager, Tony Hanwell, was present on the first day and the Operations Manager, Christine Hanwell, was present for most of the second visit. A tour of the premises took place and records/documents relating to the care of the service users, staff and the home were inspected. An Annual Quality Assurance Assessment had been completed by the Registered Manager, which contained information relevant to the inspection. Thirteen service users were spoken with or observed during the visit and one relative was spoken with during the visit. Six staff members were spoken with during the visit and two other staff were observed going about their normal duties. Four postal surveys were sent to social and health care professionals and two were returned. What the service does well: What has improved since the last inspection? The Manager has been registered with the Commission for Social Care Inspection and a qualified mental health nurse has been appointed as the Clinical Manager. A professional Chef has been recruited on a full time basis who is responsible for all aspects of menu planning, food ordering and meal preparation. The home has acquired national recognition of the way staff are trained and developed by achieving the ‘Investor in People Award’. The Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 6 organisation has purchased another vehicle, a seven seater people carrier, to facilitate more trips out for service users. 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. Priory Gate DS0000062825.V349776.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 Priory Gate DS0000062825.V349776.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): Standards 2, 3 and 4 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. The home’s admissions procedure ensures that prospective service users and their relatives/representatives know that the home will meet their needs and aspirations. EVIDENCE: The pre-admission assessment process ensures that the needs of prospective service users are identified. Any potential restrictions on choice or freedom, based on the individual needs and circumstances of service users, are discussed and agreed with the service user during this process. Service users and their relatives/representatives are welcome to visit the home prior to admission to meet other service users, staff and have a look around the home. There are also opportunities for prospective service users to have a meal or stay overnight should they wish to. If a service user is admitted at short notice, staff ensure that the person is made comfortable and introduced to the home, other residents and staff as soon as possible after admission. Discussions with service users, a relative, staff and the Registered Manager, as well as information contained in service users’ plans and observation, show that staff are aware of the needs of the service users. Priory Gate DS0000062825.V349776.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): Standards 6, 7, 8 and 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users can be confident that they will be encouraged and supported to make choices and decisions about their lifestyles. EVIDENCE: Four service users’ files were inspected and these contained care plans and risk assessments relating to health and personal care needs that are regularly reviewed. The care planning documentation contains comprehensive and detailed information about how the care needs of service users should be met by the staff team. Discussion with service users and staff, as well as observation, confirmed that personal care is maintained, service users can bathe/shower when they choose to and are encouraged to be as independent and make as many choices as possible. Information from a health/social care professional also confirmed that service users have the opportunity to live their lives as they choose, as long as this does not cause harm to themselves or others. With regard to service users’ money, the Deputy Manager confirmed that each service user is encouraged to maintain their own bank or building Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 10 society account. The Court of Protection, or relatives/representatives, administers some service users’ finances. Spending money belonging to service users is looked after by the home for safekeeping purposes. Priory Gate DS0000062825.V349776.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): Standards 11, 12, 13, 14, 15, 16 and 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users can feel confident that they will have opportunities for personal development, various activities are available to fulfil their aspirations, and independence and choice are promoted. EVIDENCE: Discussions with service users, a relative and staff confirmed that service users attend a range of work and leisure activities, including arts and crafts, physical exercise sessions and trips out for shopping or to participate in an activity, for example, bowling. Service users are also encouraged and enabled to pursue previous hobbies and interests, such as horse riding. On the day of inspection the home had been decorated for a Halloween party, that was taking place that evening, and service users said they were looking forward to it. Visitors are welcomed and can visit whenever they like. Observation showed that all the service users and staff knew the visitors and welcomed them into the home. Educational opportunities are available if required. The home has access to a Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 12 separate facility where service users can enjoy various arts and crafts and the artistic work produced adorns the walls of the home. The home employs a staff member with specific responsibility for co-ordinating and arranging various activities. The home owns two vehicles to transport service users to appointments and social events if required but service users are also encouraged to use public transport. Each service user is encouraged to have has his/her own bank/building society account and is provided with assistance, advice and guidance to manage their financial affairs should they need this. Service users said that they liked the food provided in the home and can choose what they want to eat. The home has recently appointed a professional Chef who intends to review the menus in consultation with the service users. Meal timings are flexible and service users said they are able to enjoy their meals in an unrushed and sociable atmosphere. There are limited opportunities for service users to use the home’s kitchen due to health and safety reasons. Therefore facilities are provided in the dining room, consisting of a kettle, microwave, refrigerator, dishwasher and sink, where service users can make their own drinks and snacks. Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 13 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): Standards 18, 19 and 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users can be confident that personal support is provided in the way, and at the time, that they want and need. Health care needs are monitored and advice is sought when necessary. EVIDENCE: Service user plans provide detailed information about personal, emotional and health care needs. Where service users have complex health needs, the management and staff team work hard at meeting those needs with support from local health care professionals. Feedback from two health/social care professionals said that service users are very well supported by the staff team who have worked successfully with people with complex mental health needs. The home keeps detailed records to monitor an individual’s progress and these are maintained thoroughly and consistently. External professional advice and guidance is sought when necessary from local health care professionals or social services, including psychiatric services and consultants. Visits to the doctor, dentist and other health appointments are recorded in individual files. Through observation it is clear that timings are flexible and the choice of the service user. Each service user has a designated key worker and service users Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 14 said they could discuss any personal issues with their key worker or other members of staff. The home has a separate, secure room where medication and service users’ care plans are kept. A staff member demonstrated the procedures for administering medication and confirmed that she had received training until she, and her line manager, considered that she was both competent and confident in the process. Records pertaining to the administration of medication were up to date, however there was one instance when the records said that a particular tablet had been refused, but it was not in the monitored dosage blister pack. Staff said that the service user concerned had initially declined to take the tablet but asked for it later, and it was administered. Advice was given to ensure that the records are always accurate. The Operations Manager agreed that action would be taken to ensure this did not occur again and confirmed that staff designated to administer medication have received training. Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 15 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): Standards 22 and 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users can be confident that any concerns or complaints will be listened to and addressed. EVIDENCE: Discussion with the service users, staff and the Registered Manager, demonstrated that the open culture of the home and the recognition of service users’ rights ensure that service users are protected from harm. The home has a written complaints procedure and service users are well aware of how and to whom they can make a complaint and feel free to do so. They each have a designated key worker and said they could speak to this person, the Registered Manager or any other member of staff. The Operations Manager confirmed that all staff members are expected to attend training in the safeguarding of vulnerable adults as part of the induction process. The home has a copy of the Local Authority’s Alerter’s Guidance available for staff with a procedure for notifying any alleged incidents of abuse or concern. Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 16 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): Standards 24, 25, 26, 27, 28 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users live in a spacious, clean, safe and comfortable home with a very high standard of décor and furnishings. EVIDENCE: The home is undergoing complete renovation. One side of the building was completed in November 2006 and the other side of the building is closed to service users until the renovation is finished. The part of the home that has been completed is spacious, comfortable, safe and clean with a very high standard of décor and furnishings. The service users are very pleased with the accommodation and say that the staff work hard at maintaining the cleanliness of communal rooms, particularly the carpets. Feedback from a health/social care professional also confirmed that the home is kept clean with no offensive odours. Service users’ art and craftwork is evident in all the rooms and is beautifully displayed. Service users confirmed that they are responsible for cleaning their own bedrooms if they wish to and the staff clean the communal Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 17 areas. The communal rooms consist of a large lounge room, a smaller dining room and a conservatory that is the designated smoking room. Each service user has a large single bedroom with plenty of space for individual needs and lifestyles. Every bedroom is fitted with telephone and computer points as well as facilities to receive Sky television, which are excellent facilities. The bedrooms are located on every floor of the building – four on the ground floor, ten on the 1st floor and two on the 2nd floor. The two bedrooms on the 2nd floor have a lounge room and kitchenette area, as well as a shower and toilet for their own use. This half of the home can accommodate wheelchair users on the ground floor only. All the bedrooms contain wash hand basins and five of them have en suite showers and toilets. Bedrooms are individually furnished and contain many personal possessions. With the agreement of the Registered Manager, service users may keep small, caged pets in the home. The bedrooms are all personalised by or for the service users, depending on their wishes. The type and quantity of furniture varies dependant on the wishes and needs of service users. Every bedroom has an appropriate lock on the door and a staff member confirmed that service users have keys to their rooms. The staff hold a master key to the locks so that they can be opened if an emergency should occur. The bathrooms and toilets are located close to bedrooms and communal rooms. Discussions with service users, as well as observation, showed that there are enough facilities to meet the needs of the service users and staff. All bathroom and toilet doors are fitted with locks that can be opened from the outside by staff in an emergency. The home has one level access shower room on the ground floor, which is accessible by people with mobility difficulties. There is another room with a toilet on the ground floor that has the plumbing to provide a second level access shower if required, but there was no shower in it at the time of this inspection. The building stands in its own large grounds that will be landscaped and made accessible to all the service users when the renovation of the rest of the building is complete. The laundry contains suitable equipment to wash and dry clothes and bedding. At present the service users are not able to do their own washing as this room also contains all cleaning substances that may be hazardous to health, and is kept locked. The Registered Manager confirmed that, during the next stage of the renovation work, the kitchen will be extended and a new laundry room created where service users will be able to do their own laundry if they wish to. The Registered Manager confirmed that, due to health and safety reasons, service users do not prepare or cook meals in the home’s kitchen. However there is a kettle, microwave, refrigerator, dishwasher and sink in the dining room for service users to make their own drinks and snacks should they wish to. Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 18 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): Standards 31, 32, 33, 34, 35 and 36 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users benefit from a competent, experienced, well-supported and supervised staff team. EVIDENCE: Discussions with service users, the staff on duty and the Registered Manager, as well as information obtained from two health/social care professionals, confirmed that there are always enough staff on duty to meet the needs of the service users. There are usually at least two care staff on duty during the day and a recreation co-ordinator, as well as the Registered Manager and the Deputy Manager. At night there are two waking night staff but, if needed, additional staff will be provided. In addition to the care staff, the home also employs ancillary staff including a Chef and a housekeeper. The staff members on duty were aware of service users’ needs and how to support them. Service users, relatives and health/social care professionals confirmed that the staff team are competent and skilled, and it was evident that there was a good rapport between service users and staff. Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 19 The files of three recently recruited staff members were inspected. One of these contained only one written reference although two had been applied for. The Registered Manager confirmed that he had known this person for several years and verbal references are always obtained prior to employment. He agreed to follow up the second reference immediately. Also, the file of another staff member showed that employment had commenced prior to the written references being received. The new job application forms that the home started using a few months ago do not have space for prospective staff members to write in the dates of their previous employment, therefore it is not possible to identify any gaps in employment history. The Operations Manager has established that this is due to new legislation relating to age discrimination, however has also confirmed that employment histories will be explored with prospective new staff members. Criminal Record Bureau (CRB) checks are obtained for every new staff member and the Registered Manager confirmed that new staff are never left unsupervised until all the checks and references are returned. The staff team is expected to participate in various training courses and all training and supervision meetings are documented in staff files. The staff members spoken with were confident that they receive enough training and supervision to enable them to do their jobs. New staff are expected to complete a structured induction training programme and ongoing training including adult protection, first aid, health and safety, manual handling, infection control, fire safety, medication, food hygiene, National Vocational Qualifications (NVQs) and courses related specifically to working with service users with mental and physical health needs such as epilepsy, diabetes and communication. Senior staff confirmed that they have completed a Certificate in Community Mental Health Award as this is deemed to be the most relevant course to enable them to learn more about the needs of the people they support. Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 20 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): Standards 37, 38, 39 and 42 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. The management approach is open, inclusive and positive, providing clear leadership and guidance. Service users’ rights, health, safety and welfare are protected and promoted. EVIDENCE: The Registered Manager, Tony Hanwell, has approximately five years experience of working in various care services and previous management experience in the leisure industry. He has been managing this home since early 2007 and was registered with the Commission for Social Care Inspection in June 2007. He has achieved a Certification in Community Mental Health (equivalent to a level 3 National Vocational Qualification (NVQ)) and is in the process of completing a management qualification, the Registered Manager’s Award. Discussion with the Registered Manager confirmed that he is Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 21 knowledgeable, committed and dedicated to providing the best care for the service users. The service users and staff who were spoken with confirmed that they are consulted and included in decisions regarding the running of the home. Health and safety practices are satisfactory in that equipment is maintained in good working order and staff receive training in health and safety, fire safety, first aid, food hygiene, infection control and manual handling. Inspection of the fire logbook indicated that the required weekly and monthly tests/checks of the fire alarm system/equipment are carried out. All radiators have low temperature surfaces to reduce the risk of burning and the Operations Manager has previously confirmed that thermostatic valves, to reduce the hot water temperature to a safe level, are fitted to all hot water outlets accessible by service users. The Registered Manager confirmed that restrictors are fitted to all windows above the ground floor and the windows inspected did have restrictors fitted. The Annual Quality Assurance Assessment, received prior to the inspection taking place, as well as documentation in the home, confirmed that comprehensive safety checks are regularly carried out including gas appliances, electrical equipment and hoists. All accidents and incidents are documented at the time of the event. Hazardous substances are locked away and data sheets are available should there be a spillage. The home had a visit from the Environmental Regulation Service on 19th October 2006 to check food safety and no issues were raised. The home has a quality assurance system that focuses on service users’ views and obtains feedback from service users, relatives and professionals from health and social care services. This information is collated and the outcomes discussed at management meetings to consider ways of continuous improvement in the service being provided. Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 4 3 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 4 26 3 27 3 28 4 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA34 Good Practice Recommendations The home should improve the recruitment procedure to ensure that two written references are obtained prior to a new staff member starting employment. A full employment history of new staff members should be obtained so that any gaps in employment can be identified and explored. These practices are to ensure that service users are better protected from risk of harm. Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton 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 Priory Gate DS0000062825.V349776.R01.S.doc Version 5.2 Page 25 - 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. 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