Inspection on 31/07/06 for Sandbanks

This inspection was carried out on 31st July 2006.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sandbanks 06/12/05

Sandbanks 21/04/05

Sandbanks 01/11/04

Sandbanks 11/05/04

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Thorndene

Insight - Eastchurch

Southfields

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33 St John`s Church Road

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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 Sandbanks 1 Cacklebury Close Hailsham East Sussex BN27 3LW Lead Inspector Judy Gossedge Key Unannounced Inspection 31st July 2006 14:00 Sandbanks DS0000042776.V302326.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 Sandbanks DS0000042776.V302326.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. Sandbanks DS0000042776.V302326.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandbanks Address 1 Cacklebury Close Hailsham East Sussex BN27 3LW 01323 843234 01323 441796 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.eastsussex.gov.uk/socialcare East Sussex County Council Mrs Jacqueline Anne Vanbergen Care Home 19 Category(ies) of Learning disability (19) registration, with number of places Sandbanks DS0000042776.V302326.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is nineteen (19). Service users must be aged between eighteen (18) and sixty-five (65) years on admission. Service users with a learning disability only to be accommodated. One named service user assessed as requiring nursing care, can use the facilities at Sandbanks to be provided with respite care. 6th December 2005 Date of last inspection Brief Description of the Service: East Sussex County Council (ESCC) runs Sandbanks. It is a purpose built property on two floors, situated in its own grounds in Hailsham, about one mile from the town centre. Service user accommodation comprises of seven single bedrooms, lounge, and kitchen/diner area on the first floor for the use of the long stay service users. Respite and short term care is provided within three single bedrooms, a separate kitchen/diner and lounge in a separate flat let, a bed sitting room and a further eight single rooms, with a lounge and large dining room all situated on the ground floor. There are assisted bathing facilities in the home. Level access is facilitated between the ground and first floor by the provision of a passenger lift in the home. There is a garden at the side of the home and a central courtyard. Fees charged are in accordance with ESCC policy and procedures and at the time of the inspection the weekly contribution service users pay for a service at Sandbanks is £0 - £62.35 a week depending on the outcome of a financial assessment. There are no additional charges but service users pay directly themselves for social activities, transport costs towards work placements and daycentres, contribution towards trips and outings, clothing and personal items, hairdressing, chiropody and college course fees. Sandbanks DS0000042776.V302326.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours on 31 July 2006. Prior to the inspection a pre-inspection questionnaire was sent to the home to be completed with information required as part of the inspection process. The information provided is quoted in this report. A tour of the home took place including communal areas and a sample of service users bedrooms. Rotas and care records were also inspected. There were thirteen service users resident and for four service users the care that they received was reviewed as part of the inspection process. Seven service users were spoken with in the lounges. Due to communication difficulties it was not possible to speak to all service users individually and so the opportunity was also taken to observe the interaction between staff and service users in the communal areas. Ten service user surveys were sent out and three completed surveys were returned after the inspection. The Registered Manager, a senior care officer, a team leader, three support workers one of who was new to the staff team and the administrative assistant were all spoken with. Ten support workers surveys were sent out and three completed surveys were returned after the inspection. Two relatives who are visitors to the home were subsequently contacted and spoken with on the telephone. Two General Practitioners comment cards were sent out, but no completed cards were returned. What the service does well: There is a detailed Statement of Purpose, Service Users Guide, and feedback from service users who have stayed in the home to give prospective service users and their carers’ information about Sandbanks. The homes environment is good, providing an attractive and homely place to live. Service users are encouraged and supported to pursue their own interests and hobbies. There was evidence that service users were enabled to have choice and flexibility in daily routines, meals and activities. Service user and relatives comments received were, ‘I have been looking forward to coming in to Sandbanks’, ‘I am very well treated’, ‘I like it here’ and ‘Sandbanks is first class’. Sandbanks DS0000042776.V302326.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sandbanks DS0000042776.V302326.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 Sandbanks DS0000042776.V302326.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed information about Sandbanks is available to be viewed prior to any admission to the home. There are pre-admission procedures in place to ensure that service users are appropriately placed at Sandbanks. But where service users are admitted for periodic respite care, updates of individual service users care needs should be evidenced and recorded for staff to reference. Service users are to be protected by the provision of a written contract/terms and conditions with the home. EVIDENCE: There is a detailed Statement of Purpose, Service Users Guide and regular quality assurance information collated for service users and their carers to read. The Manager stated these documents are sent out to new service users for them or their representatives to read. A copy of the last report is available to read in the entrance to the home. Two service users surveys stated they had received information about Sandbanks prior to moving into the home and one added, ‘I like it here’. One service user felt the question was not applicable. One relative of a new service user spoken with, confirmed receipt of adequate information prior to admission, that they were aware of where the last inspection report is kept and that it is available to read if they wish to. There was one new service user resident at Sandbanks at the time of the inspection. So it was possible to evidence that a Social Care Assessment had Sandbanks DS0000042776.V302326.R01.S.doc Version 5.2 Page 9 been completed with the new service user by staff from one of ESCC’s Adult Social Care Department’s Assessment Teams. This had been sent to the home to reference and there was documentary evidence of trial visits and discussions prior to the admission. Staff will also go to meet new service users and their carers/representatives to gain information to help them provide the care needed. Where service users are admitted for periodic respite care the updates of individual service users care needs should be evidenced and recorded for staff to reference. Where one service user had been admitted for a period of respite care, the service user stated ‘I have been looking forward to coming in to Sandbanks’. It was not possible to evidence on the service users documentation viewed, but the Manager stated that a written contract between the home and the service user detailing the terms and conditions of any period of care provided is in the process of being introduced. This is being discussed where possible with service users through the review process in place at Sandbanks. Sandbanks DS0000042776.V302326.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users individual plans are detailed and provide the staff team with the information they need to ensure that service users individual care needs are met. But these should be subject to regular review. EVIDENCE: Four service users individual plans (profiles) were viewed, which were detailed, and these are drawn up where possible with the service user. A review process is in place in the home, but for two service users the documentation viewed did not evidence a regular review to ensure that the agreed goals are being met. During the inspection support workers stated for one of these service users just admitted for a period of respite care a review was planned to be held during their stay. One relative spoken with was able to confirm that a review of the care needs of their relative was in process of being completed. Supporting risk assessments were also seen to be in place. Service users were observed being given opportunities to make decisions in all areas of their daily living whilst at Sandbanks. Sandbanks DS0000042776.V302326.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged and supported to participate in appropriate activities, maintain community links and pursue their own interests and hobbies. The meals provided in the home offer both choice and variety. EVIDENCE: Service users continue to attend their daily activities as they would at home, and several of service users returned to Sandbanks that evening from day care facilities attended during the day. Service users were observed and some spoke of participating in a range of leisure activities. A number of service users decided to go out for a drink at a local pub; some service users stayed at Sandbanks and listened to music in their own room or watched television. The pre- inspection questionnaire also detailed that service users are supported to access the local community for example for shopping, trips to the cinema or theatre, swimming and ten pin bowling. The service user surveys all stated ‘yes’ where asked, ‘can you do what you want during the day, in the evening and at the weekends’. Both the Sandbanks DS0000042776.V302326.R01.S.doc Version 5.2 Page 12 relatives confirmed that they are welcomed to the home and maintained contact by visiting or by telephone contact. One comment received was that, ’Sandbanks is first class’. On the residential unit the tea was prepared by a support worker working on the unit and was fish fingers, spaghetti and potato wedges. The menus are chosen by the service users on the unit with the support of the support workers to ensure a healthy balanced diet is provided. One service user confirmed they helped with the choice of menu. Two service users resident on this unit stated that the food was good. Staff were observed discussing with service users what they would like for their packed lunch to take with them the next day, when attending their chosen activity. On the respite unit evening meal was also being prepared by a support worker as there were no catering staff on duty that night. There is a six-week rotating menu in place detailing a choice at all meals and all service users were observed choosing from the choice available. The evening meal consisted of pizza, sausages, chips or roast potatoes, vegetables, salad followed by assorted yoghurts, which all the service users ate, some with assistance. Their evening meal was appetising and well presented. Support workers and service users ate together and discussed their day and the proposed evening activities. The mealtime was relaxed and friendly. Service users spoken with in the dining area well of the food provided. Sandbanks DS0000042776.V302326.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care and support is provided which is flexible and sensitive to individual service users. It was observed that positive relationships had been formed between staff and service users. There are detailed policies and procedures in place in relation to medication to protect service users. EVIDENCE: The sample individual care plans viewed, service users and relatives’ feedback, support workers spoken with and observations during the inspection confirmed that care and support given is sensitive to the individual care needs of each of the service users. Records referred to specialist advice and guidance, which had been sought. Relationships between staff and service users and the care given were observed to be very good and service users were treated with respect at all times. Service users were observed to need a range of assistance with personal and health care needs and which was detailed in their individual care plans. Where service users only stay at Sandbanks for respite care or short-term care, they remain with their own GP if local, or will visit the local surgery and register on a temporary basis. One service user had been supported to visit their GP Sandbanks DS0000042776.V302326.R01.S.doc Version 5.2 Page 14 during the day, for another who was not well guidance had been sought and support workers were monitoring the service users care needs. There are detailed policies and procedures in relation to the administration of medication. A new storage area for medication was set up in the home last year. Service users bring any medication in with them for the period of respite care and at the time of the inspection none of the service users were administering their own medication. Two support workers were observed administrating medication to service users on the respite unit after dinner. The storage and records viewed of medication administered were adequate. Support workers spoken with confirmed they had received medication training provided at Sandbanks, but it is understood that the organisation also provides further medication training/guidance for staff to meet the requirements of the standard. The Manager stated that regular visits from a pharmacist for advice and support have now been arranged. Sandbanks DS0000042776.V302326.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear and effective complaints procedure in place, which enables service users and their representatives to raise any concerns. There are detailed policies and procedures in place to protect service users from abuse. EVIDENCE: The organisation has a detailed compliments and complaints policy and procedure in place. Any complaints received are monitored through the line management arrangements in place within the organisation. Four complaints were recorded in the pre-inspection questionnaire since the last inspection, two having been investigated under adult protection procedures. The CSCI have not received any concerns in relation to Sandbanks. The three service users surveys stated they knew who to speak to and how to make a complaint. The two relatives spoken with had not made any complaints, but felt it was an environment where they could raise any issues, were aware of the procedures and knew who to speak to. There are detailed policies and procedures in place in relation to the protection of vulnerable adults and a whistle blowing policy. The three staff surveys stated staff were aware of adult protection procedures. The support workers spoken with all confirmed they had an awareness of adult protection procedures. Staff training records also detailed staff attendance at this training. Sandbanks DS0000042776.V302326.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment continues to be improved so that service users are provided with a safe, attractive and homely place to live. EVIDENCE: A tour of the building was made. Décor in the home is to a good standard, with furnishings of a good quality and domestic in style following the refurbishment of the home in 2003. The large lounge and seating area has been redecorated and a new floor covering provided, which has further improved the environment. There are nineteen single bedrooms of which eleven do not meet the minimum space requirements. A sample of the bedrooms was viewed. Where possible particularly service users who are being accommodated on the long stay unit have been encouraged to select the colour of their bedroom and their own furniture. Some of the bedrooms viewed reflected a range of individual styles and interests. Sandbanks DS0000042776.V302326.R01.S.doc Version 5.2 Page 17 There are no en-suite facilities, but there are sufficient toilets, and a selection of assisted bathing facilities in the home. There are several communal areas for service users to use, a kitchen dining room and lounge on the long stay unit, a lounge in the flat let, a large dining room with seating area and a further lounge for respite and short term care service users. Service users were observed during the inspection using all these facilities participating in a range of activities. There is a passenger lift between the ground, and first floor within the home to facilitate level access. The home was clean and free from offensive odours. All service users and relatives feedback confirmed the home was kept fresh and clean. Laundry facilities are provided in the home. The Water Supply Regulations 1999 are met and a risk assessment in relation to Legionella is in place. There is a large garden with an attractive seating area. The small inner courtyard now has a water feature and seating for service users. Routine fire checks of the building were viewed and were adequate. Sandbanks DS0000042776.V302326.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate staffing was in place on the day, but staffing levels need to be kept under review to ensure service users care needs continues to be met. Robust recruitment procedures were demonstrated to be in place. EVIDENCE: The home was calm and relaxed on the day of the inspection and the staffing in place was adequate to meet the needs of current service users resident. It enabled staff to accompany service users on a trip out during the evening, one service user to have one to one support and service users remaining in the home to be supported in their chosen leisure pursuits. Support workers were also cooking the evening meal on the respite unit, but stated there was usually catering staff to cook the evening meal with support workers only covering when the catering staff are not available. There was not full occupancy of the home and staffing levels should be kept under review to ensure that the care needs of the service users continue to be met. Feedback from support workers spoken with and records viewed confirmed there has been further recruitment of support workers. This and that staff rotas have been reviewed has lead to less reliance on relief and agency staff to provide staff cover in the home. The feedback also indicated a good and Sandbanks DS0000042776.V302326.R01.S.doc Version 5.2 Page 19 supportive team. Feedback from the support workers surveys stated that ‘the unit provides a good standard of care and commitment to its service users and staff, and ‘we work as a team including management and ensure that each service user has as much support as they need and want. Staff are also very supportive of each other’. Further comments received about the staffing levels in place were ‘as more complex needs are introduced to the service the staffing levels remain the same’, ‘and ‘reassess staffing levels’. The service users surveys stated that service users felt the staff listened and acted on what they say. When asked if staff treat you well the surveys stated always or usually and one comment received was ‘very well treated’. All recruitment of ESCC staff is co-ordinated by the organisations personnel department at ESCC’s head office. Evidence of the recruitment process followed for staff is now held at the home. The Manager was able to provide evidence that all staff have completed a CRB check. The recruitment information was still in the process of being collated in the home, but it was possible to evidence the recruitment procedure in place. Five staff files were viewed, the format being used to evidence the recruitment process needs to be fully completed and signed. For three members of staff there was no photographic proof of identity. Staff confirmed during the inspection that this was in the process of being completed. Standard 28 has not been met as fifty percent of the staff have not achieved NVQ level 2 or equivalent in care by April 2005. The pre-inspection questionnaire detailed eight support workers hold an NVQ level 2 in care. This equates to thirty-two percent of the homes support workers and five further support workers are currently working towards this qualification. Induction procedures are in place which new staff recruited to the home will be taken through. The five support workers spoken with confirmed they had received an induction and one stated ‘the induction was very good’. One comment received on the support workers survey was ‘the induction process is much more in depth now with good background training for new staff. Training in general is widely available’. Support workers spoken confirmed attendance on a range of training and training updates. Staff training records completed evidenced where staff had received moving and handling updates, first aid, basic food hygiene, medication and fire training. All staff feedback confirmed that supervision is provided to meet requirments. Sandbanks DS0000042776.V302326.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall management of the home is good with effective systems to protect service users being put in place. EVIDENCE: There is now a Registered Manager working at Sandbanks, who has worked for ESCC for a number of years. She has participated in a range of training opportunities and is in the process of completeing the Registered Managers Award. There are clear lines of line management and accountability within the organisation. An annual development plan for quality assurance is in place in the home. There are opportunities for service users and their representatives to put forward their views about the home and the care that they receive, which inform ESCC and staff in the home of the quality of the service being provided. Staff and service users referred to a service users meeting which was due to be held the next weekend and minutes of the last meeting held on the respite Sandbanks DS0000042776.V302326.R01.S.doc Version 5.2 Page 21 unit were available to read. Regular monthly visits by a representative of the organisation occur and are recorded. A sample of the incident and accident forms completed was viewed. A fire risk assessment was viewed and the Manager stated this had had a yearly review and that fire procedures were in the process of being reviewed in the home. A detailed check of the environment and fire precautions had been carried out to meet the timescales as detailed in ESCC’s policies and procedures. ESCC has confirmed the fire training to be undertaken at Sandbanks to meet requirements. The Manager stated that this was in the process of being implemented in the home and that training records would be completed to detail the training undertaken. The organisation has a system in place to evidence that the maintenance of equipment and services has been carried out. Eight of the hot water taps from wash-hand-basins and baths were tested and were all close to the recommended safe temperature of 43.0°C. Recoding of the regular checks of the hot water temperatures undertaken were also seen. A system needs to be in place to ensure that the CSCI is notified of any significant events in the home. Sandbanks DS0000042776.V302326.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 3 2 2 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X Sandbanks DS0000042776.V302326.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. 1. Standard YA2 Regulation 15 (2) (b) Requirement That the care plan is subject to regular review. Where service users are being provided with regular respite care the updates of individual service users care needs should be evidenced and recorded for staff to reference. That a system is in place to notify the CSCI of significant events in the home. Timescale for action 30/09/06 2. YA42 37 (1) 30/09/06 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 Sandbanks DS0000042776.V302326.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. Extracts may not be used or reproduced without the express permission of CSCI Sandbanks DS0000042776.V302326.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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