Inspection on 30/10/07 for Reeves Court

This inspection was carried out on 30th October 2007.

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

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

Other inspections for this house

Reeves Court 09/10/09

Reeves Court 16/01/07

Reeves Court 30/11/05

Reeves Court 11/07/05

Reeves Court 28/09/04

Reeves Court 29/06/04

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

CARE HOME ADULTS 18-65 Reeves Court Reeves Court Reigate Road Leatherhead Surrey KT22 8NR Lead Inspector Damian Griffiths Unannounced Inspection 30th October 2007 10:30 Reeves Court DS0000036664.V346787.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 Reeves Court DS0000036664.V346787.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. Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Reeves Court Address Reeves Court Reigate Road Leatherhead Surrey KT22 8NR 01372 389446 01372 389416 sparish@seeability.org 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) SeeAbility Susan Jane Parish Care Home 25 Category(ies) of Dementia (1), Learning disability (25), Sensory registration, with number impairment (25) of places Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons usually to be accommodated wil be: 18 - 65 Years The service may provide care in respect of one named individual within the category of Dementia (DE). 16th January 2007 Date of last inspection Brief Description of the Service: Reeves Court is located in the SeeAbility complex in Leatherhead, Surrey. It is close to local facilities and amenities. It was purpose-built and divided into four units, one of which is currently empty. Day to day management of Flats 1,2 and 4 is under the supervision of 3 deputy managers, all reporting directly to the manager. To the front of the building is a small pleasant patio area. Reeves Court provides care and accommodation for up to 25 residents in the category of younger adults. Residents have learning and sensory disabilities (visual impairment) and display some degree of challenging behaviour. The basic cost of the service is £1,814.16 per person per week. Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and took 6 ½ hours commencing at 10:30am and ending at approximately 5pm. Mr Damian Griffiths Regulation Inspector completed the visit and the Registered Manager, Susan Parish, representing the establishment was present. The inspector ensured that time was spent observing talking and noting interaction between care staff and service users. Service users relied on relatives and care staff to meet their care needs and in some cases speak on their behalf. A tour of the premises was conducted and samples of service users care need assessments, care plans and the views of service users met during the visit contributed to this inspection report. No CSCI surveys were available prior to the inspection. Staff files were inspected for evidence of good practice in the following areas; recruitment, training and the distribution of care staff skills as planned in the staff rota for the day. The inspector would like to extend thanks to the service users and staff at Reeves Court for their time and hospitality. What the service does well: There were no requirements made during this inspection as the home met or exceeded the National Minimum Standards inspected. The home had produced an all-inclusive assessment of the care needs of new and existing service users. The home was committed to service users ability to gain independence within their own community and at home following the completion of competent and thorough risk assessments. The best interest of the service user was being respected and implemented on a daily basis by the active person centred work being undertaken at the home. Service users were provided with a unique care plan tailored to meet their care needs; cultural, religious needs, routines and provision of nutritious meals. The healthcare needs of service users benefited from the commitment of staff to ensure that these were implemented in a way that service users preferred. The home’s complaints system ensured service users were able to contribute and had the opportunity to discuss their concerns at any time. Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 Page 6 The home was actively involved with safeguarding the service users from the threat of abuse. Service users were well supported and safeguarded by care staff that had acquired the skills and training necessary to meet their care needs. The home environment provided to service users was designed to meet their needs now and in the future. The style of management promoted positive outcomes and personal development benefiting service users and staff within the safe and homely environment of Reeves Court. 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. Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 Page 7 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. Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 was inspected and the quality in this outcome area was good. The home had produced an all-inclusive assessment of the care needs of new and existing service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four (4) examples of the homes assessment process were examined including details of a new service user to the home. A comprehensive account of all aspects of the new service user was in place and undergoing review. Existing service user files examined contained information relating to care needs, personal choice likes and dislikes, communication needs and behavioural characteristics. Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 were inspected and the quality in this outcome area was good. The home was committed to service users ability to gain independence within their own community and at home following the completion of competent and thorough risk assessments. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans of four (4) service users contained information that enabled the care staff to understand the complex care needs of the service users of Reeves Court. The inspector observed the interaction between staff and service users to establish whether their care plans were still applicable and met current assessed care needs. The information provided in the care plan or ‘Support Plan’ was relevant to the service user’s care needs showed that regular reviews had been undertaken. There was a wealth of information available, about service users care needs therefore’, an easy to read basic summary of care needs had been produced and including, how the service user preferred their daily care support was to be provided, such as, bedtime routines “ I like to lay in bed with my lights on”. Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 Page 11 Staff had worked hard to ensure that service users could express their needs vocally or by use of other forms of communication including hands on sign language that was observed on the day of the inspection. Complete details could be found recorded in the support plans. ‘Support Plans’ also included a list of risk assessments and details of care support highlighting service users support required and the potential risk to service users and care staff ensuring a reasonable degree of safety had been awareness had been promoted when engaged in daily activities. There was also a separate folder that contained just risk assessments for reference. A further three (3) ‘evening’ care plans were inspected to see what measures were in place. Guidelines described how best to meet each service user’s care needs throughout the night, such as; risk assessment, special diets, ensuring movement sensors were on, occasional medication needs and how to best manage service user anxiety. Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11, 12, 13, 15, 16 and 17 were inspected and the quality in this outcome area is excellent. The best interest of the service user was being respected by the active person centred work being undertaken at the home. Service users were provided with a unique care plan tailored to meet their care needs including; cultural, religious needs, routines and the provision of nutritious meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In order to ensure that service users were being supported to actively take part in ordinary life within the community records of their every-day life at the home were inspected. Daily records, available within the care plan folder, showed that service users had been supported to participate within the local community, attending; local college, places of worship, restaurants, and shops and going for a ride in the home’s car was happening on a regular basis. Five care staff had also participated in the homes ‘Social Inclusion Programme’ that promoted positive ways that staff could support the service users to assess local facilities and services within the community. Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 Page 13 The inspector was introduced to the service users throughout the home and they confirmed that they enjoyed visiting the shops, church with friends and family and eating out. Cultural, religious and individual rights were respected and service users were supported to attend religious services. Recording equipment known as ‘assisted technology’ had been provided to promote good communication between staff and service users. Service users consulted during the inspection that they saw their family, friends and a married couple were supported in every way to maintain their relationship. The inspector observed that digitally produced photographs had been placed in one service user’s diary to better illustrate communication when visiting his parents. ‘Focused’ service user work had been implemented by the allocation of key/rehab workers specialising in promoting independence and awareness resulting in individual goals being achieved. This approach had enabled one service user to brush his own teeth after many years of being dependent on staff for this daily task. The homes Annual Quality Assurance Assessment (AQAA) also confirmed that it would continued with; ‘In-control’ focus”. Respect for service users privacy was witnessed as each care staff member made a point of knocking on doors before entering each flat and addressed each service user in the way that they understood and felt comfortable with. Reeves court consists of four self-sufficient flats with a kitchen-diner area. This enabled a relaxed approach to every day cooking and the participation of the service users whenever possible. Menus consisted of meals chosen by service users, usually on Sunday’s and containing a regular balance of fresh fruit and vegetables and fresh fruit was available in every area. Records of individual dietary needs was also in place and service users were observed receiving meals in a careful and supportive manner throughout the day. The inspector discussed the daily food options available with service users and staff and inspected the kitchen-diner area. A folder containing all the foods liked and disliked by service users, weekly menus, essential foods and favourites, such as chicken curry was stored was kept up to date and in daily use, as was evident by it’s battered and worn condition. Reference to service users choice of meals was also to be found in the minutes of service user meetings. A new ring binder was found to replace the old and battered kitchen folder on the day of the inspection. Reeves Court DS0000036664.V346787.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): Standards 18, 19, 20 and 21 were inspected and the quality in this outcome area is good. The healthcare needs of service users benefited from the commitment of staff to ensure that these were implemented in a way that service users preferred. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff had been directed to the specific healthcare needs and personal support needed for the home to meet service users healthcare needs by ensuring service users had received extensive assessment of their communication The ‘healthcare action plans’ inspected contained detailed account of what each service users healthcare needs were, how to implement regular healthcare checks, risk assessment and records of hospital/GP appointments. A ‘going in to hospital’ profile had also been developed to help nursing staff. As mentioned in the previous section, a service user healthcare was improved by enabling him to independently brush his teeth. The independence programmes introduced by key and rehab workers provided good healthcare provision in the same focused way as mentioned earlier in the report. In addition a recording device affectionately known as the ‘Big Mac’ due to it’s Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 Page 15 shape enabled service users to listen to messages or leave messages for staff and recorded information such as, reminders of hospital/GP appointments. The homes Annual Quality Assurance Assessment (AQAA) confirmed that policies were in place to inform staff how to safely administer medication to service users. Only trained care staff were permitted to dispense and administer medication. The supervision and administration of medication was the responsibility of the homes deputy managers in control of each flat. The Medicines Administration Records (MAR) of three service users were examined and found to include a corrected record of the prescribed daily dosages administered by authorised care staff. Care had been taken to ensure the continuity of administration when service users visited relatives and friends by providing relatives with copies of Medicines Administration Records that showed evidence of being completion. Individual medication protocols were in place including guidelines of medication given ‘as required’ and the disposal and storage of unused medication. Unused or spoilt medication had been appropriately secured and stored. Records of the medication were checked and corresponded with the medication waiting to be returned to the pharmacy. All returns had been recorded and signed by the pharmacy used. Sadly, since the last inspection the death of a service user had occurred. The home had responded by alerting appropriate emergency services and the necessary authorities. Friends of the service user at the home had received sensitive support from care staff and discussions about the loss of a valued service user could be found recorded in the service users (meeting) minutes. The home had tackled this difficult area with service users and relatives and recorded “Wishes at Death” on service users files for reference. Reeves Court DS0000036664.V346787.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): Standards 22 and 23 were inspected and the quality in this outcome area was good. The home complaints system in use ensured service users were able to contribute and had the opportunity to discuss their concerns. The home was actively involved with safeguarding the service users from the threat of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had endeavoured to ensure that the service users had access to a complaints system and that complaints were regularly recorded in a folder with a tactile front cover was available in the flats inspected. Audio and braille versions of the complaints system were in place as stated in the homes Annual Quality Assurance Assessment (AQAA). There were no complaints recorded in the folder inspected however there was evidence recorded in the minutes of service user meetings that indicated that service users were able to discuss things that they were unhappy about, such as; objects removed from a bedroom and requesting more liver sausage for dinner. A recommendation made at the last inspection suggested that service users should be reminded about the complaints system. This was difficult to establish however the minutes of the service users meetings and the actions listed in this report demonstrated that this will be an ongoing objective for staff at Reeves Court. There had been no complaints reported to CSCI since the last inspection but the homes Annual Quality Assurance Assessment (AQAA) had recoded fourteen (14) complaints with a 100 response rate within the 28 day response period as stated in the homes complaints policy. Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 Page 17 The home actively promotes safeguarding vulnerable adults and staff were aware of the issues of abuse relative to the service users in their care. Evidence was in place to show that the home worked jointly with the established authorities when abuse or the potential for abuse was suspected. The homes Annual Quality Assurance Assessment (AQAA) confirmed that it had activated the ‘Surrey multi-agency procedures’ for the safeguarding of vulnerable adults and contacted the local social care teams on three occasions since the last inspection. In one instance reported to the CSCI by the home, as required in Regulation 37 of the Care Home Regulations (2001), joint work with the local social care teams had been organised and resulted in the joint decision that the incident was not abusive and did not merit further investigation. There was evidence to show that the home had been able to improve the life of one service user with challenging behaviour by helping him to speak to staff about his concerns and fears. In all instances the correct procedures had been followed. The homes SeeAbility brochure stated; “We believe that each person has the same human value and rights as anyone else and the right to services and community inclusion”. Reeves Court DS0000036664.V346787.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): Standards 24, 25, 26, 27, 29 and 30 were inspected and the quality in this outcome area is good. The home environment provided to service users was designed to meet their needs now and in the future. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector was given a tour of the premises by staff and service users. The home environment was comfortable clean and tidy offering a mix of homeliness and the practical use of equipment, such as; hoists, hospital beds, electronic bathing equipment to ensure safety of staff and service users. The home was showing signs of wear and tear in most areas, particularly communal bathrooms, as had been noted in the previous report. The home had taken care to ensure that cracks in bath equipment had been made safe. Front doors to service users bedrooms contained different tactile objects familiar to service users that promoted confidence and independence when assisting service users to identify their room. With the service users permission, the inspector was able to visit bedrooms that mirrored the Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 Page 19 individual preference of each service user. One bedroom contained a calendar system comprising of wooden shapes that represented the days months and years in order to assist the service users knowledge and understanding of his daily routines, activities and encouraged independence and confidence. Assistive technology such as sound boxes, movement sensors, recording equipment and the use of contemporary digitalised equipment was in regular use. Laundry areas and sluice rooms provided clean and sanitary place to ensure that the health and safety of the service user was respected. One sluice room had been deemed surplus to requirement due to the purchase of a washing machine with a sluice facility. Service user bedrooms, communal bathrooms and living spaces were clean and pleasant. SeeAbility had submitted plans to the local authority for the rebuilding and development of the home complex and area that had been approved subject to local consultation. Service users had been consulted and suggestions for new names for the developments had been recorded in the service users minute books. In the light of this development CSCI accepts that it would be unreasonable for the requirements made at the last inspection to be implemented and the inspector was confident that the home would carry out regular risk assessments to ensure the health, safety and welfare of the service user. Reeves Court DS0000036664.V346787.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): Standards 32, 34 and 35 were inspected and the quality in this outcome area is good. Service users were well supported and safeguarded by care staff that had acquired the skills and training necessary to meet their care needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three (3) staff files were inspected to ensure that staff training and skills matched the service users care needs. Staff rotas covering ‘waking’ night staff from three different flats were inspected and skills and training compared with certificated evidence of training on file. Care staff had acquired skills including; infection control and food hygiene and NVQ level 4, first aid, visual impairment awareness, safeguarding vulnerable adults, epilepsy management and medication administering skills were in place to meet the care needs of the service users. Staff confirmed that they were encouraged and supported to meet all their training needs and the homes Annual Quality Assurance Assessment (AQAA) confirmed that 54 of staff had acquired level 2 of the National Vocational Qualification (NVQ). Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 Page 21 As mentioned throughout this report care staff had also received training specific to service user needs in relation to: Equality, diversity, social inclusion, care needs and rehabilitation related work. A robust staff recruitment process that protected the needs of the service users was in place. A staff file of a care worker recently recruited was amongst the three (3) files inspected. Each file was presented in good condition with well-documented sections containing: job applications and employment history, references, identity documents, criminal record checks and to assist the reader. All was in order. Reeves Court DS0000036664.V346787.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): Standards 37, 38, 39 and 42 were inspected and the quality in this outcome area was excellent. The style of management promoted positive outcomes and personal development benefiting service users and staff within the safe and homely environment of Reeves Court. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager of Reeves Court had been in post for two years and over 10 years experience in management. She had obtained her Registered Managers Award (RMA) and NVQ level 4 social care. Staff confirmed that they were able to access regular training updates. Staff felt supported and able to approach the manager and deputy manager in place and an ‘open-door’ policy was practiced. Staff at the home were friendly, open, co-operative enthusiastic and professional in the approach and execution of their work. Time had been taken to promote service users basic and everyday rights; of choice at home, Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 Page 23 essential care needs, access to the community, and activities as budgets allowed, healthcare and cultural and religious needs. Staff demonstrated particular skills that had been developed to meet the complex behavioural and communication needs of each service user. Staff had delivered care support in a sensitive and consistent way that had become familiar the service users who were able respond and expressed themselves. Written evidence in place and observation during the inspection confirmed that significant progress had be made in this area since they had been at Reeves Court thus fulfilling and exceeding the National Minimum Standards. The home was focused on the every-day needs of the service users and the need to constantly review how these would be best met. The recording of service users views and the overall needs of the home in general were regularly scrutinised by an efficient managerial system of internal audits as required in regulation 26 of the Home Care Regulations, Quality Assurance surveys or ‘Satisfaction surveys’, health and safety risk assessments. As recommended at the last inspection, the home recognised that it could improve the way it publicises successful outcomes with all stakeholders and was endeavouring to improve in this area. The homes Annual Quality Assurance Assessment (AQAA) stated that they could do better; to develop ways in which we can demonstrate how the service has supported people to achieve outcomes/developments year on year. The home was aware of the health and safety implications relating to the need to rebuild/redevelop of the Reeves Court complex. The inspector was confident that any outstanding repairs would continue to be made safe. Attention to fire safety and fire drill was well documented and equipment such as: space blankets and fire extinguishers were in place and the home received a successful Environmental Health visit on the 14th February 2007 and confirmed as providing “a good standard of food safety and cleanliness”. Reeves Court DS0000036664.V346787.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 3 25 3 26 3 27 2 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 3 3 X LIFESTYLES Standard No Score 11 4 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 4 4 3 X X 3 X Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 Page 25 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 Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Reeves Court DS0000036664.V346787.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!