Inspection on 10/11/06 for Sunnybank

This inspection was carried out on 10th November 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 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

Sunnybank 28/10/08

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Sunnybank Elizabeth Court Elizabeth Drive Castleford West Yorks WF10 3SD Lead Inspector Mr Tony Brindle Unannounced Inspection 10th November 2006 10:00 Sunnybank DS0000067799.V319774.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 Sunnybank DS0000067799.V319774.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. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunnybank Address Elizabeth Court Elizabeth Drive Castleford West Yorks WF10 3SD 01977 559458 01977 559458 sunnybank@mcare.info Not available Millennium Care Services Limited 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) Miss Catherine Anne Fraser Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Sunny bank is a large detached house in Airedale a residential suburb of Castleford. The home is located in a community setting, close to all local facilities, i.e. shops, pubs, libraries, hairdressers, churches (all denominations), GP surgeries and transportation links. The accommodation is comprised of a six bedroomed two-storey house and two bedroomed single story detached self-contained annexe. The extensive garden area is shared by both properties and enjoys a covered seating area adjacent to a pond with waterfall, that affords a sense of calm and relaxation. The annexe facilitates a more independent way of life for the occupants as they are supported with everyday tasks, such as cooking, cleaning, washing and managing their own budget. The property has good sized and safe gardens. There is good access via local transport to the nearby town of Pontefract and to Castleford town centre, which is further enhanced as the home has use of its own transport. The home is registered for eight adults who have learning disabilities and primarily specializes in providing a service to those who may challenge mainstream services. Each person has his or her own bedroom. Six people are accommodated in the main house with the other two people being accommodated in the annexe. The annexe provides people with greater opportunities in which to develop their independent living skills whilst still accessing the homes facilities. People are assisted to access local facilities, college and leisure opportunities within the community by a committed staff team. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 5 The current fees for November2006 start at £1678. The service provider ensures that information about the service is available to prospective service users and the current service users by way of the home’s Statement of Purpose, the Service User Guide and through CSCI inspection reports, which are available within the home and upon request. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. • As part of this full inspection, a visit to the home took place. • The inspector, Tony Brindle, visited the home unannounced. • Whilst at the home, key documents such as care assessments, care plans, daily records and the home’s policies were looked at, and so were the rooms and garden. • 4 service users were spoken with. • 3 members of staff were spoken with, along with the manager. • Comment cards were sent to a number of service users relatives, 3 visiting professionals and 2 GPs. • 50 of the comment cards were returned to the Commission prior to the visit taking place. • Feedback was positive with people saying that they felt welcome. What the service does well: The manager makes sure that people are given information about the home, and the service before they move into the home. People’s needs are assessed before they move into the home. People’s needs, desires and goals are set out in the plan of care which the staff can follow so that people’s needs are met. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 7 Individual decision-making is effectively promoted. It is clear that the daily routines and rules about living in the home promote independence, and individual choice. People’s medication needs are met by an excellent system for dealing with medicines brought in to the home. The manager and staff make sure that people’s health care needs are recorded and met by making sure they have access to health care professionals and services. People living at the home take part in a variety of activities. People get to go out and use the facilities within the community. The staff are well trained. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 8 There are very good systems in place for making sure people are kept safe. 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. The summary of this inspection report can be made available in other formats on request. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 9 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 Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The work of the staff and the systems operated at the home make sure that people only move into the home once assurances have been given that their assessed needs can be appropriately met. EVIDENCE: The deputy manager at the home said that admissions are not made until a full needs assessment has been undertaken. The manager along with the company’s nurse, usually undertake the assessments. One person living at the home confirmed that they were given the opportunity to spend time in the home before they moved in. The records show that assessments are carried out with the individual, and their family or representative, where appropriate. Staff from the home go to visit prospective service users, and obtain as much information as possible from the person and their representative. Where the assessment has been undertaken through care management arrangements, evidence contained within people’s files showed that a summary of the assessment and a copy of the care plan is obtained by the manager of the home. It is clear from the information contained within people’s files that significant time and effort is spent making admission to the home personal and well Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 11 managed. Prospective service users and their families are treated as individuals and with dignity and respect. The manager and staff place a high value on responding to individual needs for information, reassurance and support. The home has developed a comprehensive Statement of Purpose and Service User Guide, which is very specific to the service user group and considers the different styles of accommodation, support, treatment, philosophies and specialist services required to meet their needs. The information can be out put in a format suitable to the needs of individuals, and their families, for example, appropriate language, pictures, Braille. Staff use innovative methods to make the information they give meaningful and interesting, for example some homes may use leaflets, photographs, or videos. All new service users receive a full comprehensive needs assessment before admission and it is clear from the records and people’s comments that this is carried out by staff with skill and sensitivity. The service is highly efficient in obtaining a summary of any assessment undertaken through care management arrangements, and insists on receiving a copy of the care plan before admission. It is clear from the records and people’s comments that the assessment focuses on achieving positive outcomes for people and this includes ensuring that the facilities, staffing and specialist services provided by the home meet the ethnicity and diversity needs of the individual. Prospective service users are given the opportunity to spend time in the home. An individual member of staff is allocated to give them information, special attention, help them to feel comfortable in their surroundings, and enable them to ask any questions about life in the home. All service users receive a Contract to which they have agreed, it gives clear information about fees and extra charges which is reviewed and kept up to date. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. The systems and procedures operated by the staff at the home make sure that the assessed needs of the service users are set out in a plan, ensuring that their health, physical and social needs are recorded, along with the actions needed to be taken by the staff. Individual decision-making is effectively promoted. Independent risk taking is supported by individual risk assessments based on individual need. EVIDENCE: Personal plans reflects people’s changing hopes, choices, needs and responsibilities. Staff develop with people living in the home a personal plan that details their needs and preferences. The plans set out how individual needs will be met in a way that people living in the home find acceptable. Personal plans include information and decisions about: Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 13 • what people like to be called; • what people like to eat and drink; • how people spend their time and what people like doing; • any equipment and adaptations people may need; • who should be involved in reviews of their care; • any communication needs people may have; • their individual health needs and how these should be met (where appropriate, they take account of their ethnic and cultural background); • their arrangements for taking any medication including any need to inform professionals; • an independent person to contact if people want to raise a concern or make a complaint; and • any measures of restraint which staff may have to use for their own safety or for the safety of others. People living at the home can receive a copy of their personal plan to keep. Each person also has a ‘Life Book’. These are completed by the service user with the help of the staff, and are personalised with pictures and objects personal to them. Personal plans are reviewed every month, or sooner if people want. Individuals may choose who should be involved in the development of their personal plan and in its reviews. Discussions with staff at the home showed that they know that the home has a written policy and procedures on the conditions under which physical intervention/restraint is used. The training records show that the staff have received training in safe and appropriate use of physical intervention/restraint. If it is necessary to restrain people on certain occasions this is written into their personal plan and records kept are of any incidents involving their restraint. The ethos of the home is to supported individuals to make decisions and choices about their life, and to get the support and care they need. Aims are set out in individual personal plans. Individuals are supported to make choices and decisions about day-to-day aspects of their life and about how they spend their time. People can keep up relationships with friends, relatives and carers and links with their own community. If people want, the staff will support individuals to do this. If a person’s personal plan says an individual should have opportunities for education, training and work, staff will help the person find these. Staff do a lot of work to give people access to college courses, community education, voluntary work and other learning. A new keycode locking system has recently been added to the kitchen door, following an incident were a service user entered the kitchen and was disruptive, throwing items around the room, and potentially putting themselves and others at risk from scalding etc. A discussion took place with the manager regarding this, and the need to not only ensure people’s individual safety, but also ensure the movement of people around the home is not unduly restricted. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 14 A sample of the risk assessments were looked at, and these were seen to identify risks such as scalding injuries in relation to the use of the kitchen. The manager acknowledge that individual risk assessments are required, and she also said that she would speak to the company’s Head of Service and Health and Safety Officer in relation to devising ways in which individual’s can be supported to use the kitchen facilities safely. In relation to other aspects of decision making, the staff spoken with understood that people have the right to make decisions about their life and care in the home. For a few individuals, however, individual circumstances will limit this opportunity for example, if people lack the capacity to make a decision. Under these circumstances, the staff undertake an appropriate risk assessment, with the person concerned. The manager said that a sensible balance is offered to people in everyday events and activities, between the reasonable risks and the safety of the staff and other residents. This was evidenced within the home’s records. It is clear from the records and people’s comments that the key principles of the home for delivering a quality service are based on the belief that people should be able to take control of their lives. The staff of the home are committed to supporting all service users including those with limited communication or intellectual skills to make informed decisions, understand the range of options which are available to them and have the right to take responsible risks. The service user plan is developed in partnership with the service user, based on an efficient assessment. The plan clearly sets out how specialist requirements will be met through positive and planned interventions. Innovative methods are used to enable people to participate and communicate their views to the development of their care plan and the review process. The plan focuses on current needs, development of skills, and future aspirations of the individual. This follows the principles of person centred approaches. it is clear from the records and people’s comments that staff have the necessary training and skills to support and encourage the individual to be fully involved. Where people have limited communication, staff are skilled in using other methods of engagement. A key worker system provides additional support enabling one to one involvement. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. It is clear that the daily routines and rules about living in the home promote independence, and individual choice. EVIDENCE: Individual choices of food and drink vary, as do dietary needs. People have their own needs and choices, and these are met. This was evidenced within the home records. This was supported by a staff member who talked about good food being important in maintaining good health. How people spend their day is up to them. However, there are a number of organized activities that individuals can and do get involved with. Staff will respect the wish of individuals to be on their own. People can entertain their friends and relatives in their own room. Although individuals are living in a care home, service users continue to be very much part of their own community, and enjoy ordinary daily life. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 16 It is clear that the daily routines and rules about living in the home promote independence, and individual choice. Central to the home’s aims and objectives is the promotion of the individual’s right to live an ordinary and meaningful life, both in the home and in the community appropriate to their peer group, and to enjoy all the rights and responsibilities of citizenship. People are enabled to enjoy a full and stimulating lifestyle with a variety of options to choose from. it is clear from the records and people’s comments that the staff have sought the views of the people and considered their varied interests when planning the routines of daily living and arranging activities both in the home and the community. Routines are very flexible and residents can make choices in major areas of their life. The routines, activities and plans are people focused, regularly reviewed, and can be quickly changed to meet individual residents needs. The service actively encourages and provides varied opportunities for people to develop and maintain social, emotional, communication and independent living skills. The service has a strong ethos and focuses on involving people in all areas of their life, and actively promotes the rights of individuals to make informed choices, providing links to specialist support when needed. This includes developing and maintaining family and personal relationships. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. The systems and procedures followed by the staff at the home make sure that the healthcare needs of people, including medication requirements, are assessed and recorded, and opportunities are created to make sure these needs are met. Service users receive personal support in the way they prefer and require. EVIDENCE: If individuals need to take medication, staff know this and there are arrangements in place for individuals to take their medication safely and in the way that suits people best. People can choose whether to manage their own medication unless there are specific reasons that prevent this. An appropriate assessment takes place in relation to this. When managing their own medication, individuals will be given their own lockable storage to keep their medication in their room. If people need it, they will also have special storage somewhere else (for example, in a fridge) that is secure and accessible to people. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 18 If on medication that someone else needs to administer (for example, an injection), external nursing and healthcare staff will do this as set out in the personal plan. This was evidenced within the people’s care plans. Personal plans describe the way people will receive the individual support and care that people need. Individuals can expect that their personal plan will change as their needs for support change. This was evidenced within the care plans. People are registered with their a GP and dentist. If individuals have been receiving community healthcare services (for example, physiotherapy, speech and language therapy, occupational therapy or advice on their diet) and still need them, this will continue. Otherwise, the staff will make new arrangements for people. If individuals have been receiving hospital healthcare services, and still need these, they are supported and helped to get this. This was evidenced within the care plans and confirmed by service users. If a care review shows that people need help or advice, for example, from a speech therapist, dentist, GP, dietician or someone else, staff will arrange this and help people to follow any advice they have been given. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 19 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are safeguarded by way of very good systems operated within the home. External agencies such as the Commission and Social Services are kept informed of incidents. The staff are well trained and aware of how to respond to complaints and incidents. EVIDENCE: Physical intervention is used only as a last resort by trained staff and only then to protect the rights and best interests of the service user. The staff team try to prevent a service user from reaching the point where physical intervention becomes necessary i.e. de-escalation. Concise recordings was seen where any physical intervention had been initiated. Staff have had received training in the use of physical intervention procedures. This was evidenced within the home’s training records. The home has polices and practices that safe guarded the handling of people’s monies. Appropriate policies and procedures in relation to safeguarding people are in place and staff are not employed to work at the home before all appropriate checks have been undertaken. Policies and procedures are in place with to safeguard people in relation to confidentiality, fire, emergencies and missing persons. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a clean and comfortable home. EVIDENCE: It is clear from touring the building that the home provides a physical environment that is appropriate to the specific needs of the those who live there. Individuals said that they are encouraged to personalise their bedrooms. The shared areas were seen to provide a choice of communal space with opportunities for people to meet relatives and friends in privacy of their own rooms. The home has recently had a contained episode of Legionella which was located within a hot water tank. All the necessary precautions have been taken, and an external water safety company are currently monitoring the water quality. The company’s Head of Service anticipates the hot water tank will not be used in the future, and an appropriate hot water boiler will be fitted. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 21 being decomission. The records show that there are other satisfactory infection control measures in place. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 22 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 and 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living at the home are supported by a well trained staff team, and they are safeguarded by an efficient staff recruitment system. EVIDENCE: The service has a well-developed recruitment procedure. This was evidenced within the records. The service has a well-developed internal training system which compliments formal training. This was evidenced within the records. The roles and responsibilities of staff are clearly defined and understood, which is based on accurate job descriptions and specifications. The deputy manager talked about seeing the induction and any probationary period as being an extension of recruitment. There are contingency plans for cover for vacancies and sickness and there is little use of any agency or temporary staff. This was evidenced within the records. The interview and selection process is based upon identified criteria that are closely related to the job being advertised and supports the procedure. All elements of recruitment are accurately recorded and the required documentation is always received prior to the employee starting work. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 23 Staffing levels reflect the needs of the people living at the home, and rotas are flexible to fit around the lifestyles of individuals. Key workers have specific allocated time to spend with individuals. Staff were seen to have the skills to communicate effectively with people living at the home. Records relating to staff meetings are used for consultation, training and the involvement of staff in the development of the service. Minutes are taken and made available to staff and service users (if requested). Individual supervision sessions take place regularly and staff say that they find them useful for their development. Notes are taken which include action plans. This was evidenced within the records. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 24 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): 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. EVIDENCE: The manager has the required competencies and skills to run the home. The staff said that they feel there is a strong culture of being open and transparent in all areas of running of the home. The service has sound policies and procedures, which the manager and organisation effectively reviews and updates, in line with current thinking and practice. Efficient systems are in place to monitor staff adherence to policies and procedures during their practice e.g. direct observation, supervision and team meetings. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 25 The health and safety records were found to be of a good standard and are routinely completed. The service has an annual quality assurance scheme, which involves sending surveys out to people associated with the home. The Commission awaits the results of the annual survey. Weekly health and safety checks are carried out, along with weekly medication checks. Management visits take place on a monthly basis, as do health and safety and medication audits. The home is externally reviewed on a annual basis in relation to health and safety issues. Despite the fact that the recent episode of Legionella was contained, and no one was affected, the manager was reminded that appropriate measures must be put in place to ensure that the regulation of water temperatures within the home are maintained, and that an appropriate solution is found to control the risk of further episodes of Legionella. The manager was aware of this, and she and the company were found to be looking into dealing with this issue as a priority. The outcomes in the areas could have been judged as excellent, but until the issues relating to Legionella are resolved, the rating for this section are seen to be good. Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 26 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 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 4 X 4 X 3 X X 3 X Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 27 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 Sunnybank DS0000067799.V319774.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Brighouse Area Office St Pauls House 23 Park Square (South) Leeds LS1 2ND 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. 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