Inspection on 20/12/06 for St George`s

This inspection was carried out on 20th December 2006.

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

St George`s 07/12/05

St George`s 06/02/05

St George`s 12/08/04

St George`s 26/02/04

Similar services:

2 Perhaver Park

The Vicarage

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Stallcombe House

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

CARE HOME ADULTS 18-65 St George`s Well Close House Lansdown Parade Cheltenham Glos GL50 2LH Lead Inspector Kath Houson Key Unannounced Inspection 20th December 2006 10:00 St George`s DS0000016585.V324467.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 St George`s DS0000016585.V324467.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. St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St George`s Address Well Close House Lansdown Parade Cheltenham Glos GL50 2LH 01242 511237 01242 242627 stgeorgesassoc@aol.com www.stgeorgesassociation.co.uk St George`s Association Ltd 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) Mrs Pamela Joan Osbaldstone Care Home 10 Category(ies) of Learning disability (10) registration, with number of places St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: Saint George’s is a Regency Grade II listed building that provides residential accommodation for ten women with learning difficulties. The Well Close House is part of Saint George’s association that was set up 109 years ago. Well Close House is one of three projects owned by the charity. The home is set in its own attractive and extensive grounds in the front and a water garden to the rear of the building. Additionally within the grounds there are four bed-sit units for supported living tenants. The home is close to Cheltenham Town centre a mile away from Montpellier and its facilities. There is good local transport and the home has the added advantage of a volunteer car service. Accurate information about fees were provided at the time of inspection and range from £353-£666 per week. Weekly fees are agreed during admisson to reflect individual need(s). Prospective admissions are given information about the home including copies of the Statement of Purpose and Service Users’ Guide which includes some information about what is covered by fees. St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of the ladies using the service. The term “ladies” will be used throughout this report, as this is what they would like to be known as rather than the term “residents”. The unannounced inspection took place one day in December 2006. The manager was unavailable throughout the inspection. The members of staff were able to assist in a positive manner creating a working partnership with the Commission for Social Care Inspection (CSCI) Twenty two-key and one-non key standards were examined. This included an examination of documentation; three care plans that were case tracked (this is a method used to carefully examine and link various aspects of the ladies care within the home). A tour of the environment is to explore the physical side and obtain a visual account of the home. A short discussion with several of the ladies, a member of staff, and a student social worker formed part of the inspection. A short succinct feedback was given to conclude the inspection visit. The inspector would like to extend her thanks to the ladies of Saint George’s care home, staff and management for their assistance with the inspection. What the service does well: What has improved since the last inspection? What they could do better: No recommendations or requirements were made on this occasion. St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 6 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. St George`s DS0000016585.V324467.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 St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has a sound admissions procedure and makes steps to meet the needs of the ladies who are admitted into the home. The ladies of Saint George’s residential home each have a Statement of terms and conditions for the home that is individualised and personalised. EVIDENCE: The home had a recent admission since the last inspection. The information was gathered from all the relevant sources. This was evident in the lady’s files and showed that the information gathered was detailed. The home additionally encourages a visit to the home this entails tea visits and overnight stays. This ensures that the potential resident can obtain a true picture of their place of choice. The home additionally has the facilities to assist the ladies with any issues around financial entitlements. The selected files looked at were detailed, well recorded and organised. The assessments of the potential admissions are assessed by competent individuals and are able to assess individual needs. For instance help is provided for potential admissions if a particular need is St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 9 required. During an assessment, information was gathered that the lady has several interests. These interests were met via signposting to college courses. During the inspection the ladies assisted with the inspection by providing information about their admissions procedure. Good accounts were given on previous accommodation and were compared to their present place of choice. The ladies said, “ the home is very fair and the staff are very supportive.” Another comment was “I like it here.” Aspirations are met via the Individual Programme Plans (IPP) then the care plans are reviewed with the idea to put in place the main objectives and outcomes all in discussion with the ladies of the home and their key worker. Each lady has a Service User Guide and Terms and Conditions for the home in their files. Theses documents set out the conditions of the service provided. The ladies know what their costs are and their entitlements, which are based on assessed needs. Each lady has access to their files and documents and permission was obtained to examine these personal files during the inspection. Feedback forms state that enough information about the home was provided before moving in and the ladies all answered positively. On the whole this service operates at an excellent standard. The ladies of the home were settled and claimed that they are cared for appropriately. For instance one comment made “ I am very happy living at Saint George’s.” The staffs’ main philosophy is that all the ladies have the right to a good quality of life. This was evident throughout the inspection, the home was positively active and the ladies were supporting each other in various aspects of the home. St George`s DS0000016585.V324467.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): 6, 7 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The ladies are given support to ensure that their individual needs are met. There are good frameworks in place for recording the ladies progression. An effective structure, which assists the ladies in their decision-making, promotes independence and autonomy. Good systems are in place for care planning and for assessing and managing risk. EVIDENCE: The home provides opportunities for the ladies to develop their skills in daily living. This is obtained by the means of positive reinforcement. Each lady discuss with their key worker their needs and aspirations. Excellent procedures are in place to capture those objectives into their care plans. During the St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 11 inspection the ladies were able to share their care plans. The ladies said in their feed back forms “ that they get good advice and help with financial issues.” Selected care plans were examined during the inspection. Documents were found to be well-recorded and contained relevant guidance for care staff to follow. Each selected document had signatures of the ladies who had at the time of inspection given permission to share their files. The signatures of each lady demonstrated that the files were regularly reviewed, this is good practice and this shows that each individual had been involved in any decisions made on the topic of their welfare. It was also identified that some of the ladies in the home have interests. The staff team provide support via sign posting and providing information that facilitate independence. An example that can be seen was during a previous inspection it was evident that preparation was being made to organise a seminar and the ladies were to give a presentation. This was successfully accomplished. The presentation was available during the inspection and an explanation was provided. The outcome demonstrates that this service assists the resident ladies to achieve and aspire to their goals. The selected risk assessment files seen and a recent move within the house that had taken place demonstrates that the ladies are encouraged and supported to take risks as part of an independent lifestyle. This was evident. The ladies comments, “ I am supported by given the information, I am very happy here.” It was also evident that each lady cares for and supports each other in the home. Additionally, the risk assessment plans have detail short medium and long-term plans for managing risk, which has been linked, to each individual skill of the ladies. The service has a timetable of daily events; key-workers monthly updates, which were seen during the inspection with assigned, agreed chores. For example, one lady said “I cooked the evening meal last night…” On the whole this service takes into account the ability of each resident lady and provides support according to need. Regular updates were provided with assistance from other agencies. The ladies are also encouraged to go at their own pace and choice is promoted with support and consideration. Respect and dignity of each lady of the home is maintained and promoted and this is also evident throughout the inspection. Another comment from the ladies was that “its better here than where I was before.” St George`s DS0000016585.V324467.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): 12, 13,15,16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The ladies are encouraged and supported to participate in culturally appropriate activities in a variety of venues. Contact with family friends and advocates are promoted assisting the ladies to develop and maintain important relationships. The ladies have flexible routines which reflects their individuality and choice. A balanced healthy diet is encouraged and maintained. EVIDENCE: The selected care plans show that the ladies have active lifestyles and attend a number of venues. The activities the service offers, is dependent on individual packages. Such activities include; swimming, horse-riding, drama, pottery a St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 13 variety of college courses such as child care and child-minding, living life skills, beauty therapy, some work in the workshops. Additionally some attend the Star College in which the ladies enjoy the classes there and assist in building their self-confidence. The subjects on offer are realistic and appropriate. Some ladies additionally have the opportunity to participate in the computer course such as the European Computer Driving Licence (ECDL), which is a qualification in all aspects of computer usage. For instance, how to use a database including how to run and set up queries, Excel and formulae in spreadsheets, presentation and designing of slides for presentations, and word processing. The ladies are armed with a number of skills, which promotes their independence. In addition to their activities it was evident during the inspection that the ladies are involved in running their home that forms an essential part of their lives. Comments made by the ladies include, “ …made a good choice of home” “ if I had any worries I would go to key-workers.” The ladies additionally have regular house meetings to discuss a number of issues that affects them within the home. For instance a meeting was held to discuss the recent change of the living facilities within the home. The ladies demonstrated such care and consideration for each other within the home that this was evident during the inspection. Discussion around the change of living arrangements was shared during the inspection by a number of the ladies each giving their own account in a positive and uplifting manner. There appears to be a strong element of respect between the ladies each having their own room key and showing that their independence is visible. The home had an air of energy on the day of inspection and the women were eager to give their account of their life in the home. The ladies are also encouraged to attend their own individual planning meeting in which the discussion around their progress is reviewed and monitored. Adjustments are made with the ladies knowledge and also ensure that their needs and aspirations are addressed. Based on the activities and the busy lifestyles the ladies are involved in also encourages and promotes friendships outside of the home. During the inspection an advocate was visiting. Comments made include… “ this home is very caring and the ladies are so talented.” The ladies are supported to attend any religious establishment as part of their choice and lifestyle. The ladies “read the church lessons and participate in house groups at the church.” The service has a four-weekly rolling menu that contains healthy options. Each lady is supported to take it in turns to organise and plan meals. This involves food preparation, cooking for numbers within the home and offering an alternative menu of choice. On the whole this service takes into account the needs of the ladies within the home, the staff demonstrate that support is provided and the ladies are confident enough to share their experiences, it would appear that the home is inclusive. St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Support is provided with personal care and healthcare which promotes dignity and wellbeing. Good frameworks are in place to ensure that the safe handling of medicines is maintained. EVIDENCE: The selected care plans and discussion with the ladies reveal that the ladies discuss their preference about how their care is delivered. The staff team were able to describe how they provide the support and address individual preferences to personal and healthcare. This was evident during several discussions with the resident ladies who collectively said, “the staff always treat me well.” St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 15 Healthcare records provided evidence that the ladies have access to and support with specialist services that is according to their needs. The staff team for instance with GP were able to review medication leading to a decrease. The resident ladies said, “ since coming of all my medication I feel so much better…” This is a proactive and positive step, a good achievement for the service that has been consistent with observing the needs of the ladies within the home. All members of the staff team are qualified in the safe handling of medication. The preparations of medications are carried out in a safe environment. The home additionally has an up-to-date copy of the British National Formulary (BNF). There also is a dedicated person who is solely responsible for the medicines that come into the home. The medication cabinet is of good standard and the medicines are stored in an orderly fashion with date of opening. The recording on the ladies medication sheets show consistency and no gaps were detected. The procedure for secondary dispensing is satisfactory. On the whole this service has good frameworks in place for meeting personal and healthcare needs. This is combined with the safeguarding and minimising of risk when administering medication. The outcome for the ladies is that they feel more confident knowing that the support is available. St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a clear complaints procedure that is accessible. The ladies are able to share their views and opinions on a regular basis. The service has good frameworks in place which ensure that the resident ladies in the home are safeguarded from harm and abuse. EVIDENCE: The service has a complaints procedure that has been placed in each individual file. The home has had no complaints since the last inspection that is a good reflection on how the service operates. The home has recently produced a newsletter that can be used as a medium for feedback. The home aims to distribute the newsletter twice a year. In addition the ladies have regular house meetings in which if there any issues for concern then the opportunity is made available. The home actively seeks to maintain staff training that safeguards the ladies from abuse and harm or neglect. A training matrix was evident and the training programme for 2007 is being currently being arranged. St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The environment is homely comfortable and promotes the ladies independence. The home is fresh and clean thus promoting their quality of life. EVIDENCE: Well Close House is a large detached house set in its own gardens. The home has ten bedrooms, one communal lounge, a dinning room, kitchen with dinning facilities and a separate laundry room. All bedrooms have a wash hand basin and there are three bathrooms and two separate shower rooms. The doors have locks and the residents each have their own key. A site visit has been recently been made to inspect new living facilities within the building of Saint George’s. The transformation has been conducted to standard and the ladies are very pleased with the completed work. The St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 18 environment is in good decorative order. There is a spacious kitchen and that is well organised. The garden is well maintained and the pool garden has bungalows, which caters for supported living tenants who are not part of the house and have their own private contracts. The environment is homely and comfortably decorated and is within easy access into Cheltenham and its surrounding area. The ladies live in a family type atmosphere in a household that is exclusively for women with learning disabilities. Comments from the ladies are: “The home is clean and fresh.” No offensive smells were detected at the time of inspection. St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The staff team are effectively skilled for the tasks they perform. A robust recruitment and selection procedures exists in the home. The home has an organised training and development system in place. EVIDENCE: There currently exist committed long-standing, staff who deliver good levels of support to the ladies who have an understanding of the ladies needs. This was evident from the continuous conversation and written documentation that demonstrate that the ladies are supported in the home. The staff team are competent and skilled in the tasks that they perform which support the ladies. Information taken form the pre inspection questionnaire states that 85 of the staff team have National Vocational Qualification (NVQ) of level two and above. This exceeds the National Minimum Standard that states that the number of staff including any agency staff achieves NVQ level St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 20 two and above is 50 . This service has achieved this and is evident that this service provides care of a quality nature. According to staff feedback forms the staff are supported by their manager. Although supervision sessions were not assessed on this occasion it was evident that staff were being supervised on a regular basis. The comments from the staff feedback comment cards on the whole read positive that that comment include “ it’s beautiful and very positive place” additionally the “ communication is good.” Random staff files were selected and demonstrates that the home’s recruitment and selection procedure are robust. This reveals that the home’s objective is to safeguard the ladies within the home and ensure that only the right people are employed. St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service is well managed promoting positive outcomes for the resident ladies which results in an effective team of staff. The service has a good system in place that monitors the service provision. The health and safety is managed well, which further promotes the well being for both staff and the resident ladies of Saint George. EVIDENCE: The home has a committed manager who is focused and knowledgeable. The manger has a strong commitment to partnership working with the Commission for Social Care Inspection (CSCI) in order to maintain a good standard of care within the home. There are procedures in place according to the size of the home and it is evident that openness and respect is given towards the ladies in the home. The approach of the manager creates an open, positive atmosphere this was evident during previous conversations prior to inspections and St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 22 witnessing the extensiveness to which the ladies feel at ease within their own surroundings. Furthermore, the responsible person has displayed a warm commitment to the home over a long period of time to enable members of staff to grow with training and support. The ladies also comment “ I am just very happy living here and enjoy the constant company, although I would like to hear music played in the home.” The record keeping in regards to the ladies information is kept in good order adhering to data protection policy. Additionally documentation is kept in a secure and confidential place within the home. All documents were produced on request with detailed explanation to how procedures are conducted. The ladies additionally have access to their files and are well aware of the information that is contained within. The ladies were openly satisfied to share the information during the inspection and would often flip to the relevant pages on request. The opinions of the ladies are addressed to ensure involvement, openness and respect in which the ladies are valued and that their voice matters. Notes from the recent house meetings were shared during the inspection. Relevant documents also show pictures of the ladies and contain hand written comments made by the ladies on how they would like their home to be managed. Additionally, the equal sharing of household chores between the ladies and the staff team demonstrates how the home functions on a homely and consistent basis. The communications officer and health and safety officer document all relevant issues and have regular monthly meetings to discuss various topics relating to the home and the needs of the ladies. Additionally, the equal sharing of household chores between the ladies and the staff team demonstrate how the home functions on a homely and consistent basis. The communications officer and health and safety officer document all relevant issues and have regular monthly meetings to discuss various topics relating to the home and the needs of the ladies. During the inspection a student social worker was sharing quality assurance data. The data was collected from the ladies of the home, and the stakeholders. The information that was fed back was positive, and depending on the respondent the need to continually develop their business plan is an ongoing task. The home appears to have a good and positive link with the trustees. St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 3 X 4 X 5 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 4 X 4 4 X St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 24 None Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 St George`s DS0000016585.V324467.R01.S.doc Version 5.2 Page 26 - 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. 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