Inspection on 29/05/07 for Tavistock Avenue (5).

This inspection was carried out on 29th May 2007.

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

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

Other inspections for this house

Tavistock Avenue (5). 12/06/06

Tavistock Avenue (5). 06/12/05

Tavistock Avenue (5). 18/08/05

Tavistock Avenue (5). 07/12/04

Tavistock Avenue (5). 27/07/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Tavistock Avenue (5) 5 Tavistock Avenue St Albans Hertfordshire AL1 2NQ Lead Inspector Mrs Jan Sheppard Unannounced Inspection 29th May 2007 10:00 Tavistock Avenue (5) DS0000019561.V339915.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 Tavistock Avenue (5) DS0000019561.V339915.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. Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tavistock Avenue (5) Address 5 Tavistock Avenue St Albans Hertfordshire AL1 2NQ 01727 843545 01727 843545 FP 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) Cherry Tree Housing Association Miss Janet Winsett Deane Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th June 2006 Brief Description of the Service: The home is a two storey semi-detached house in a residential area of St. Albans. It is owned by Cherry Tree Housing Association and is situated close to the city centre with easy access to public transport. The ground floor comprises a lounge, a combined kitchen dining room, one bedroom, an assisted shower room and a laundry room. Two bedrooms, a bathroom and a staff office are located on the first floor. The home provides full care services in a safe and homely environment for three service users who all have learning disabilities. The current fee for the residents who are all sponsored by Hertfordshire County Council is £837.36 per week. Recent CSCI inspection reports are available in the home for residents and visitors to read. Information regarding the service is available in the Statement of Purpose and Service User Guide. Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection site visit took place over six and a half hours and provided the inspector with opportunity to speak with the one service user at home at that time, the homes manager, one other staff member and the Chief Executive of the Cherry Tree Housing Association who own the home. The daily routine of this resident was observed a number of key records were examined and a tour of the premises was undertaken. During the day of this inspection the home had a peaceful and very homely atmosphere. The comments in this report reflect the findings made by the inspector during this visit and also take account of information gathered over the past months from the homes management and by way of the pre-inspection questionnaires completed by the residents and their relatives and friends. This was a positive inspection with the key standards examined met. There were no outstanding requirements from the last inspection. Since the last inspection the Commission has registered the manager. What the service does well: What has improved since the last inspection? Since the last inspection the home has concentrated on enabling the residents to retain and develop further their independence and to give them every opportunity and encouragement to make as many decisions about their own lives as it is safely possible for them to do. One resident is now able to make unaccompanied visits to a local shop whilst another is going on a more independent summer holiday. A number of improvements have been made to the building with new equipment and facilities provided which better meet the individual needs of the residents Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 6 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. Tavistock Avenue (5) DS0000019561.V339915.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 Tavistock Avenue (5) DS0000019561.V339915.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 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to the service. Admissions to the home are not agreed until a full needs assessment has been carried out and the home is satisfied that it can meet these needs. Sufficient information is provided for prospective residents and their families to enable them to make an informed choice about admission. EVIDENCE: There have been no new admissions to the home for the past five years. The Manager discussed with the inspector the process that has just commenced to assess an applicant for a vacancy that has very recently occurred. It was seen that this process is in keeping with the stated procedures as set out in the Admissions Policy. Good information about No. 5 Tavistock Avenue has been provided to the applicant and to their family to enable them to make an informed choice about its suitability. Information about the applicants care needs is being sought from their existing care giver, social worker and the medical services involved. Links have also been made with their relatives. The manager is taking time to make a thorough assessment of the care needs of the prospective applicant and also in assessing whether they would be compatible with the existing Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 9 residents; this aspect being particularly important in such a small home. Time and effort is being given to ensuring that any changes and exploratory visits are arranged at a time and pace that will suit their particular needs. Consideration is being given to the availability of suitable day activities in the St Albans area and also whether there would be local provision to meet their particular religious needs. The Statement of Purpose and Service Users Guide has recently been up dated to reflect the new management arrangements in the home. Each resident has a copy of this along with a copy of the Complaints Procedure, which they keep, in their rooms as their personal information. Staff take time with the residents in explaining these documents and ensuring that they have an understanding of them. Tavistock Avenue (5) DS0000019561.V339915.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): 6,7,8 and 9. People who use this service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. Good quality care plans are maintained for each resident. Their safety is supported by the good detail and regular review of their risk assessments. People who use the service have prompt access to medical services whenever these are needed. They are given every opportunity and encouragement to make as many decisions about their own lives as it is safely possible for them to do. EVIDENCE: Both care plans were very well maintained with up to date information regular reviews and detailed risk assessments, which are also being frequently reviewed. A more up to date photograph should be provided on one plan. Instructions as to the best manner in which care was to be delivered were clearly set out with helpful suggestions as to the best method of approach to Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 11 cope with re-occurring particularly difficult situations. The residents are regularly involved with their key worker in the compiling of these plans and are encouraged to sign them; evidence of their signature being seen on the plans. The detail of these plans evidence that the staff are fully committed in supporting the residents to lead purposeful and fulfilling lives as independently as possible. Discussions with the staff also evidence that they understand the importance of the residents being supported to take control of their own lives to make decisions and choices as far as it was safely possible for them to so do. Risk assessments for activities both external and internal to the home were found to be well prepared with good detail concerning the risk and its potential hazard and how these might be avoided. The risk assessment for a resident who is to go on holiday in June was well compiled with good information for their new caregivers. The manager explained that since the last inspection the risk for one resident in going out from the home unaccompanied had been reassessed as being safe and this resident did make such an outing to the local shops during the time of this inspection. They were clearly very pleased at being able to go to purchase their own magazines, which they showed to the inspector on their return. The manager told the inspector how she had explained the situation to the local shopkeeper who was empathetic and helpful and that this was supporting the home in having better connections with their local community. The reviews of the care plan set goals and objectives and also indicate where these have been met and where they are not met suggest alternatives. It could be evidenced from these review documents that the home works closely with social services and day centre staff. Tavistock Avenue (5) DS0000019561.V339915.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 and 17. People who use this service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. The residents have good quality food and their diverse activity needs are generally well supported. EVIDENCE: Both the residents have day activity programmes, which enable them to take part in age, peer and culturally appropriate activities that meet their needs and fulfil their interests. One resident spends four-week days attending various day centres where they participate in a range of practical activities and life skills classes. The fifth day is spent at home catching up with laundry, being assisted by the staff to carryout weekly banking and bill paying tasks and to catch up with personal shopping needs. They are able to spend regular time at weekends visiting their family and have a regular programme of evening social activities that also enjoy. This year they have chosen to take a holiday away Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 13 from the other home residents and to go more independently with a group of age and peer related friends on a “Door to Door” holiday. The day activity arrangements for another resident who had been enjoying and making progress with individually home based activities with a visiting organiser have now been abruptly stopped due to social service funding difficulties. The cessation of this service appears to have been without consultation with and beyond the control of the home. However the home must ensure that to give equality of opportunity to the resident and to meet their day care needs that if this programme cannot be quickly reinstated that another programme is planned and commences promptly. The residents are assisted by the staff to maintain contact with their relatives and friends and to make staying visits to them if they wish. The staff also regularly take residents out into the local community for a variety of leisure and entertainment activities and a number of home outings to local places of interest are planned for the coming summer months. The manager explained that extra day outings have been planned for the resident who has declined to have a staying away holiday this year. Both the residents are said to enjoy their food, they help with the shopping and with the meal preparation and have good opportunity to choose the menus. Being a very small home meals can easily be flexibly changed to meet immediate requirements this particularly so at weekends when participation in social activities often changes the normal routine pattern of the day. Staff reported that take out meals are enjoyed by all the residents who sometimes share these with their peers in the Associations other home which is near by. The home aims to provide a varied menu adhering to a healthy eating formula. Supplies of low fat yogurt and fresh fruit were seen to be freely available in the fridge for residents to help themselves to. However the problems of weight gain and a lack of willingness to undertake regular exercise is an area that the managers are aware of and are actively seeking to address. Unfortunately the local dietician service has now been disbanded but some help in monitoring is being offered by the GPs surgery nurse. Tavistock Avenue (5) DS0000019561.V339915.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,and 20. People who use this service receive good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. Personal Care and Health Care offered to the residents continues to be of a high standard which meets their physical and emotional needs. The medication storage and administration system is robust and gives good protection to the people who use the service. EVIDENCE: The residents all confirmed that they are well cared for in the home and this was echoed by the comments received from their relatives. One said, “ Staff at 5 Tavistock are caring, have empathy and good knowledge of my relatives needs. They are a consistent team build up good relationships with X and offer an active and interesting life as well as meeting X care needs.” Another commenting about 2 named careworkers said “ X and X often go beyond their duties to ensure that their clients are well cared for”. During this inspection the residents were observed to be being treated in a respectful manner by the staff with whom they appeared to have an easy and Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 15 relaxed relationship making their needs known in an empowered manner and also showing an awareness of the wider needs of the home. The home continues to have good working relationships with their local GPs nurses and allied health professionals who all respond quickly to their requests for help. The recent need for an emergency referral to a consultant for reassessment was promptly and helpfully dealt with and the staff commented on the support that they also received from this service following a sudden and unexpected death of a long standing resident. Following this the bereavement needs of the residents have been given good attention with external special help being provided on an individual basis where required. There have been no changes to the medication arrangements since the last inspection. The manager said that she had considered adopting a different administration system but as only a small amount of medication is currently prescribed she judged that at this time such a change was not justified. The medication records spot-checked during this inspection were all properly recorded. All staff who administer medication have been trained to do so. A Controlled Medication Cabinet has been ordered for the home. There is currently no controlled medication being administered in the home. Tavistock Avenue (5) DS0000019561.V339915.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 and 23. People who use this service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. Residents in this home are able to express their concerns and have access to a robust complaints procedure. Policies and Procedures concerning Safeguarding Adults (Adult Protection) and Whistle Blowing are in place. EVIDENCE: There have been no incidents concerning Adult Protection since the last inspection. Staff spoken with had a sound understanding of this subject and were clear when an incident needed to be referred to the local authority as part of the local safe guarding procedures. The records evidenced that all staff had undertaken training and that refresher training for Safeguarding adults is planned. Staff were aware of their extra responsibilities in this area and their need for vigilance and close observation of other signs given the limited verbal ability of the residents. No complaints have been received by the home or by the Commission since the last inspection. The complaints policy is clear and the residents as well as having this procedure explained to them regularly (usually when their care plans are being reviewed) also have a copy of this procedure given to them to keep in their rooms. Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 17 Information gathered from the resident’s relatives and friends prior to this inspection evidenced that they too had a clear understanding of the complaints procedures. Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. People who use this service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. The service offers a good environment that is generally well appointed and subject to regular upgrading and maintenance. Some areas where minor improvements are needed were identified to eliminate risk and ensure the safety of the residents. EVIDENCE: Number 5 Tavistock Avenue is an ordinary semi-detached house in a quiet residential road on the outskirts of St. Albans. The building is small and homely and has over the years has been suitably adapted to meet the needs of its three female residents so that it now provides a comfortable and safe environment which encourages their independence. On the day of this unannounced inspection the home was found to be very clean and tidy. The residents single bedrooms are well personalised with Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 19 furniture and fittings that reflect their own interests and tastes. One resident told the inspector that they were very happy with her room. Since the last inspection a number of works have been completed in the home. A Terri Step Lift has been fitted to the front entrance where steps had precluded the easy access for one less mobile resident and the side entrance to the rear of the home had been levelled and extended to similarly give better flat access to the garden. A new shower tray and drainage has been fitted to the ground floor bathroom; a new area of work surface fitted in the kitchen along with the replacement of the kitchen door guard, which had developed a fault. The home has a regular maintenance and refurbishment programme that the manager demonstrated will include the redecoration of one bedroom, which has recently become vacant. Following a tour of the building it was noted that the following environmental aspects need attention to ensure the good maintenance of the environment and the full safety of the residents. To ensure good infection control measures are in place the gap between the tiles and the work surface behind the kitchen sink taps needs to be resealed; Paper hand towels should be provided in the bathrooms for the use of staff and individual hand towels provided for all the residents. To ensure residents safety the radiator in the hallway and in the vacant residents bedroom needs to have a low surface temperature cover. The manager is reminded that curtains and soft furnishings should be fire retardant. Although the home generally had a bright and well-decorated appearance an area of paintwork and decoration in the ground floor hallway which is scuffed needs attention. The manager and resident showed the inspector the rearrangement of furnishings that had been done in the lounge making this a more spacious and attractive room which staff confirmed is used a lot by both the residents and staff. The kitchen / dining room remains a very homely room clean and well ordered it is clearly the hub of the home and was seen to be a place well owned by the resident as they prepared their own breakfast and lunch. Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to the service. Experienced and qualified staff are employed in sufficient numbers to support the people who use the service and thereby ensure the smooth running of the home. The recruitment practices are robust and ensure the residents safety. EVIDENCE: The service is fortunate in being able to retain a very stable group of staff many of who have worked at the home for many years. There are sufficient numbers of permanent and bank staff so that it is very rare to use agency staff. If agency staff are used they have had a proper introduction to the home and residents. At the last inspection the recruitment records and checks were seen to be in order and these standards were met - no new staff have been appointed since the last inspection. The one part time staff member who has left the home since the last inspection did so because of a family move from the area. Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 21 All the staff except one part time worker holds NVQ Qualifications at either levels 2 or 3. The manager who holds both levels 2 and 3 is part way through her NVQ level 4 the Registered Managers Award. In addition staff are provided with very good training opportunities with courses on First Aid, Infection Control, Fire Awareness, Food Hygiene, Medication Administration and Equality and Diversity being attended since the last inspection. A refresher course on Moving and Handling is planned for later in the year. The records evidenced that staff receive regular supervision and an annual appraisal. Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. People who use this service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. People using this service are safeguarded by the sound leadership and management approach of the home, which also provides them with a safe environment where their opportunity for independence and choice is assured. The management and administration of the home is based on openness and respect There is a good quality assurance programme in place. EVIDENCE: The new manager who has recently been registered by the Commission has the required qualifications and experience and is competent to manage the Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 23 home. She has a clear understanding of the key principles and focus of the service and her aim to continually improve and increase the quality of life for the residents along with a good awareness of the need for equality and an understanding of the diversity of their needs was clear. She reported to the inspector that she is well supported by the associations Management, receives regular supervision meetings herself and the home receives regular Regulation 26 management audit visits. Consideration should be given to linking the homes computer to the internet so that the manager can freely access essential CSCI and other information from other associated professional agencies whilst she is at work. There are clear health and safety policies and evidence of the regular management checks of these was seen. Random checks by the inspector during this inspection, (water temperature, fire accidents,) evidenced that checks are routinely carried out and usually well recorded however more detail concerning the residents reaction to the homes fire evacuation procedures should be made. Overall the maintenance of the records is well done with good detail and consistency this safeguarding the service users rights and interests. There are efficient systems to ensure effective safeguarding and management of resident’s monies. The residents are given every assistance to take responsibility for their own money as far as this is safely possible for them to so do and they are regularly assisted to make banking transactions. The residents have free access to their records; all records are kept securely and staff are aware of the requirements of the Data Protection Act. There is a well-developed Quality Assurance system. The residents, relatives and other stakeholders in the home are given regular opportunities to comment on the services they receive and the overall quality of care offered to them. The results of these surveys are then used to form part of the Associations annual report on the home a copy of which is sent to the Commission. Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 2 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 25 no 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. 1. 2 Refer to Standard YA12 YA24 Good Practice Recommendations All residents should have equal opportunity to participate in a Day Activities Programme, which meets their needs. The environment should be properly appointed and maintained so as to promote the safety for the residents and eliminate risk. See detail in this standard concerning these measures. Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Tavistock Avenue (5) DS0000019561.V339915.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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