Inspection on 19/03/07 for The Old Forge

This inspection was carried out on 19th March 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

The Old Forge 26/02/09

The Old Forge 28/02/06

The Old Forge 25/08/04

The Old Forge 06/04/04

The Old Forge 06/08/03

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

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

CARE HOME ADULTS 18-65 The Old Forge Mill Road Slapton Bucks LU7 9BT Lead Inspector Sue Smith Unannounced Inspection 19th March 2007 11:30 DS0000028058.V330969.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 DS0000028058.V330969.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. DS0000028058.V330969.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Forge Address Mill Road Slapton Bucks LU7 9BT 01525 221506 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) Turnstone Support Ltd Yok Lin Chong Care Home 4 Category(ies) of Learning disability (4) registration, with number of places DS0000028058.V330969.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: The Old Forge is a small care home that is registered to provide care and accommodation to four service users with learning disabilities. The home is administrated by Turnstone Support Housing Association and is one of several homes in Buckinghamshire that is registered under the auspices of the Commission for Social Care Inspection. The Old Forge is situated in the village of Slapton, close to the border of Bedfordshire. The home is centrally situated in the village, close to the local amenities. The nearby towns of Leighton Buzzard, Aylesbury and Milton Keynes provide the service users with a wide range of amenities. Access to the towns is via the home’s own transport. The Old Forge is a single storey building, which has been sympathetically refurbished to meet the needs of service users. There is a car park at the front of the property with spaces for approximately four or five vehicles. At the rear of the property there are enclosed communal gardens. The personal contributions of Service Users towards the fees are between £53.35 per week and £62.85 per week. These figures were provided during the March 2007 inspection and are the most up to date figures submitted to the Commission. A Statement of Purpose and Service Users Guide are available at the home and are available to potential service users on request. DS0000028058.V330969.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of The Old Forge was undertaken on the 19th March 2007 over 4 hours. The Manager was available on the day of inspection. The Inspector used a triangulated methodology to complete this inspection, pre-inspection information such as the previous report and the pre-inspection questionnaire was used in the planning process to ensure hypotheses were formulated to support the inspector to explore issues of concern and verify practice and service provision. During the inspection a variety of documentation was assessed, which included Care plans, Risk Assessments, Menus, Rotas, Training records and Recruitment records. A full environmental tour took place, with no issues of concern raised. The Inspector identified two Service Users for Case tracking, observing these Service Users and their interactions with others including staff at the home, assessing the available information held in the home relating to the care provision, checking this against observed practice. The Inspectors observed positive practice throughout the day, finding The Old Forge to be a relaxed and pleasant home with an emphasis placed on providing a person centred approach to implementing care and support. The inspector would like to thank the Service Users and Staff at The Old Forge for their hospitality and their support in completing this inspection. What the service does well: The home has a thorough pre-admission procedure, which ensures all potential service users receive adequate information prior to admission. Up to date and regularly reviewed Care plans are in place to support the individual care needs of Service Users. Risk assessments are in place, which aim to protect the service user and support them to maintain their independence. Activities are provided which include social inclusion in the local community. Service Users are supported to maintain their personal relationships, with support from staff for visiting friends and family available. Service Users are supported to maintain their levels of independence and their right to make choices in their every day lives is respected. DS0000028058.V330969.R01.S.doc Version 5.2 Page 6 Menus are planned daily and are nutritious and well balanced. Robust medication procedures are in place to protect service users. Personal support is provided in a manner that promotes independence and is in line with the personal preferences of the service user. Additional healthcare and emotional support are provided with a variety of specialist medical services available on referral. The home has a robust complaints procedure which is accessible to service users, staff and significant others. The home follows the local authority Protection of Vulnerable Adults Policy and its reporting systems, ensuring the ongoing protection of service users. The home is pleasant and homely, with recent decoration and refurbishment improving the facilities available to service users. Training which includes NVQs is provided to staff to support them in their role. Sufficient staffing levels are maintained to ensure the needs of service users are met. Recruitment systems are in place, which now includes the security checking of all sessional workers prior to employment. The home is managed by an appropriately trained and skilled manager to ensure the continuity of care and support to service users. The Organisation has a quality audit system, which provides the home with a variety of monthly monitoring tools and opportunities for service user feedback to be obtained. Robust Health and Safety systems are in place to ensure the protection of Service Users, Staff and Visitors to the home. The Staff and Management at The Old Forge have created a homely, relaxed and safe home for Service Users to enjoy. What has improved since the last inspection? The home has implemented its decoration and refurbishment plan, improving the facilities available to service users. All medication administration assessments are kept up to date and were open to inspection. DS0000028058.V330969.R01.S.doc Version 5.2 Page 7 A senior staff member or the manager always supports staff under the age of 21. Service users’ plans now reflect the levels of support they require in the manner preferred by service users. All sessional workers now have all recruitment and Schedule 2 documents in place prior to commencement of unsupervised visits with service users. Risk assessments for cot sides and the use of latex gloves are now in place. 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. DS0000028058.V330969.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000028058.V330969.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Organisation operates a thorough admissions procedure, which ensures the home is able to meet the holistic needs of a new Service User. EVIDENCE: The home has a comprehensive pre-admission assessment policy and procedure, which ensures all potential Service Users undertake a variety of assessments, which includes assessments from outside agencies to ensure the home is able to meet their needs. In addition trial periods, which begin with lunchtime stops to overnight visits, take place to ensure the placement fits the needs of the Service User. Throughout the assessment process the existing Service Users are consulted to ensure the compatibility of the proposed Service User. There have been no recent admissions to the home, however the Manager has a clear understanding of how to operate this procedure. The equality and diversity of Service Users are taken into consideration during the assessment process. There are no restrictions on admission based on ethnicity, sexual preference, cultural, religious or spiritual beliefs of a service user. DS0000028058.V330969.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 good. This judgement has been made using available evidence including a visit to this service. All Service Users have an individual plan of care in place, which supports them in a manner that addresses their holistic needs whilst living at the home. Service Users are supported to maintain control over their lives with risk assessments in place, which support them to maintain their levels of independence safely. EVIDENCE: The Organisation provides a set format for Care planning purposes, which is then completed in line with the identified needs and goals of the individual service users. The standard of record keeping within the Care plans at The Old Forge is of a high standard with all records found to be reflective of review and relevant to the identified needs of the service users. The personal preferences of service users and how best to support them to achieve the desired outcomes are reflected in the Care plan. The Home has met the required DS0000028058.V330969.R01.S.doc Version 5.2 Page 11 national minimum standard, however on assessing the Care plan it was difficult to follow due to the sheer volume of documents that are maintained, in all there are three files of documents relating to each service user, which contain relevant and active information to support staff to provide care, however some of the information is duplicated throughout the different areas of the Care plan making them hard to follow and difficult to review. It is recommended the Organisation review how the Care plan is presented, developing a workable and living document that staff can easily refer to. In addition to the home’s Care plan they also maintain a Person Centred Planning document and provide service users with a Care plan in a format suitable for them to work with. At this time the Person Centred Plan for service users is still a planning document with no actual plans developed for the service users. It was reported by the Manager that at this time there is no lead on Person Centred Planning within the Organisation, however as the planning phase has already been completed this should not inhibit the successful implementation of individual plans which are relevant to the service user. It is recommended this important work be developed as soon as is reasonably practicable to ensure service users have a plan that they can refer to in a format they prefer and can understand. All service users have individual risk assessments, which identify risk measures that will enable the service users to maintain their levels of independence safely. Risk assessments are regularly reviewed with the dates and signatures evident. Throughout the inspection service users were observed working with staff members, making choices on their daily routines and how care is implemented. There was evidence of positive relationships established between staff and service users, with staff respective of the service users’ individuality and capabilities. Interactions were relaxed and friendly with staff possessing a clear knowledge and understanding of the service users’ needs. DS0000028058.V330969.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 good. This judgement has been made using available evidence including a visit to this service. The Service Users take part in meaningful and enjoyable activities, which support their independence and personal lifestyles. Family and friends are welcomed at the home, which supports Service Users to maintain their personal relationships. Service Users are supported to express their opinions and their rights are protected through effective communication systems. Meals are effectively planned by consulting with Service Users, ensuring all menus are nutritiously balanced taking into consideration the likes and dislikes of the Service Users. DS0000028058.V330969.R01.S.doc Version 5.2 Page 13 EVIDENCE: The service users at The Old Forge are able to access a variety of community facilities, which includes local shopping, and leisure facilities. Activities at the home are planned around the individual needs of the service users with records maintained daily of any activities they have participated in. The service users are now attending the local Gateway Club, which is proving to be an enjoyable social activity. In addition to accessing the local community the service users at The Old Forge also take part in a variety of activities provided at the home, sensory equipment is available, hand and foot rubs are provided as required, table top games, DVD and Videos are available in the communal lounge and music chosen by the service users is available. Families and friends are welcomed at the home with the service users also visiting friends in other homes when invited. There are no restrictions on visiting times. Menus are planned with the service user on a daily basis as part of the independent living skills support implemented at the home. Service users take turns in deciding on the main meal for the day with staff supporting them to ensure that all meals are nutritious and well balanced. Service users then go with the staff to purchase the food at the local supermarket and then take part as far as they are able in the preparation and cooking of the meal. On the day of the inspection service users were observed taking part in this activity which was well managed, with staff including the service user in all aspects of the meal preparation, cooking and serving, with their personal capabilities taken into consideration. Any dietary issues are referred to the PCT dietician for support as required. DS0000028058.V330969.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 good. This judgement has been made using available evidence including a visit to this service. All care is implemented in a supportive and sensitive manner ensuring flexibility in times to suit the personal preferences of Service Users. A range of healthcare professionals is in place to support the ongoing and changing needs of Service Users, which is supported by the home’s staff, thus protecting Service Users. Robust medication procedures are in place, which ensure the protection of Service Users. EVIDENCE: Support to service users for personal and intimate care is delivered in a sensitive and professional manner. Service users are able to maintain their levels of independence with staff ensuring their privacy and dignity are maintained at all times. DS0000028058.V330969.R01.S.doc Version 5.2 Page 15 The service users at The Old Forge have a variety of needs that require staff support; all care is based on the personal preferences of service users with care implemented at flexible times to suit the service user. There have been no complaints or concerns raised directly to the home or the Commission in relation to the provision of personal care. Service users appeared relaxed and happy around the staff with staff communicating effectively with service users ensuring their needs are met. All preferred personal care support is documented in the Care plan. In addition to the care and support provided by staff, the service users benefit from other professionals such as their G.P. Psychiatric Consultant, Optician and Dental specialists. Visits can be arranged at the home should the needs of the service user require these services. Presently service users are able to access the practice offices of these professionals with staff support. The home provides support to service users for the safe handling, storage and administration of medications. MAR (medication administration records) sheets are maintained by suitably trained staff with no gaps evident on the day of inspection. Staff training in medication administration is now implemented annually to ensure all staff are deemed competent to deliver this important part of the care package. All records pertaining to the medication systems of the home are held in individual files relating to specific service users. This includes copies of staff training, medication risk assessments and consent forms. Again as noted in the Care planning section of this report the Inspector has questioned the relevance or necessity of duplicating such things as the training record for medication in individual service user files. The medication cupboard was found to be clean and tidy with no out of date medications held in the home, dates of opening were evident on all bottles, and vessels holding creams, lotions and ointments. A system of ordering and returning unused medications is in place with records open to inspection. There were no outstanding issues in regard to the medication procedures at the home with the home fully meeting the national minimum standard. DS0000028058.V330969.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 home has a comprehensive complaints procedure which supports Service Users and significant others to make a complaint appropriately. The home ensures the protection of its Service Users through regularly updated Protection of Vulnerable Adult training, and policies and procedures, which support the protection of Service Users against abuse. EVIDENCE: The Organisation provides the home with a complaints procedure which is accessible to service users, staff and significant others. The home has received one complaint since the last inspection, which was in relation to noise from the garden in the summer months. This complaint was investigated and copies of correspondence on the findings were held on file with the original complaint. There have been no further complaints received at the home or directly to the Commission since the last inspection. The home provides all staff with regularly updated training in the protection of vulnerable adults. In addition, the Organisation provides a policy, which is in line with the County’s policy for Safeguarding Adults. There have been no allegations or reports of abuse at the home since the last inspection. DS0000028058.V330969.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 good. This judgement has been made using available evidence including a visit to this service. The Old Forge provides a safe, pleasant and homely environment for Service Users to enjoy. EVIDENCE: The Old Forge is a pleasant and homely environment with adaptations and equipment fitted to enable service users to live comfortably and safely. Since the last inspection a decoration programme has been implemented to further improve the facilities available to service users, this includes decoration of the main corridors and the fitting of guards to protect the walls from damage caused by wheelchairs, the painting of some service users’ bedrooms (with other planned for decoration) the repair and redecoration to damp areas identified at the last inspection and the replacement of soft furnishings. Since the last inspection there has been another leak causing minor damage to one service user’s bedroom, this is scheduled for repair and redecoration, which will be implemented as soon as is reasonably practicable. There were no other DS0000028058.V330969.R01.S.doc Version 5.2 Page 18 repairs necessary to the home, which may affect the health and welfare of service users. The home is kept clean and tidy by the staff team, with a cleaning schedule in place, there were no offensive odours present on the day of inspection with the home found to be cleaned to a high standard. DS0000028058.V330969.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 good. This judgement has been made using available evidence including a visit to this service. The home has a thorough recruitment procedure, which is reflective of good practice, thus protecting Service Users. All staff receive ongoing training, which supports their professional development and ensures the needs of Service Users are met by a knowledgeable and professional staff team. EVIDENCE: The Organisation implements a thorough recruitment system which ensures all relevant security checks such as CRB disclosures with POVA checks are implemented prior to employment. There has been one staff member employed since the last inspection with all relevant documents held on file at the home, these include two written references, CRB disclosure information, Application forms, proof of identity and interview notes. DS0000028058.V330969.R01.S.doc Version 5.2 Page 20 The Organisation operates an equal opportunities policy with the staff employed at the home representing a wide range of skills, ethnic groups and ages. There have been no issues related to the recruitment of staff with the home fully meeting the national minimum standard. All staff receive ongoing training, which ensures mandatory training such as manual handling, food-hygiene, first aid, fire safety and Health and Safety are regularly updated. In addition to the mandatory courses staff have also attended a variety of other courses to support their professional development and aid them in their duties, these include Person Centred Planning, Disability and Equality, PCP Awareness, Value Based Practice, Epilepsy, Risk Assessing, Autism Awareness and Working Within Professional Boundaries. There is a good emphasis placed on training within the Organisation with the Home accessing as many courses as possible to improve their knowledge of the service users in their care. In addition to training, NVQs are also provided with over 50 of staff employed at the home completing an NVQ 2 or NVQ 3. DS0000028058.V330969.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): 37, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by a suitably skilled Manager who ensures the needs of the Service Users are met at all times by a knowledgeable and supportive staff team. The Organisation implements a quality audit system, which ensures the views of service users are reflected and acted upon when developing the home. The home ensures the health, safety and welfare of Service Users are protected through robust systems, which are maintained to a high standard. DS0000028058.V330969.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Manager is suitably skilled and experienced in her role; she has completed her Registered Managers Award and NVQ 4, which compliments her original nursing qualifications. She has worked with the service users at The Old Forge since the home opened with previous experience of working as a nurse at their previous hospital placement. Staff reported the manager as approachable and supportive. Service users were relaxed and happy around the manager and her staff team with a homely supportive culture evident throughout the home. The Manager ensures her own professional development by attending courses throughout the year. The Organisation has a quality audit system in place, which provides the home with a number of monitoring tools, which are submitted to senior management within identified timescales. The views of service users are sought through a service user survey as well as regular advocate and service user meetings. All minutes taken from the service users/staff meetings are then provided for the service users in picture format, using photos where necessary as well as pictures of such things as furnishings (used when discussing the type of new couch they would like). Unfortunately the advocate/service user meeting notes have not been provided in a format that can be understood by the service user and is something that the Manager may want to consider for discussion when next meeting with the Advocate. The Organisation provides the home with an up to date Health and Safety Policy, which is reflective of current legislation and guidance. The home has a variety of monitoring and assessment tools, which are used to ensure the ongoing health, welfare and safety of service users, staff and visitors to the home. Risk assessments are in place, which identify areas of risk throughout the internal and external environment of the home, with risk measures identified, which enable service users to maintain access and independence in their home. Maintenance records were open to inspection with all maintenance to the building implemented within reasonable timescales after reporting. The only outstanding maintenance issue at the home is the area of damp that has appeared in one service user’s bedroom, this has been scheduled for repair and redecorated which will be implemented as soon as is reasonably practicable. Fire systems are regularly monitored with weekly alarm tests, regular fire drills, and fire safety equipment regularly maintained by the contracting company. The home recently had a Fire Authority Inspection with all areas DS0000028058.V330969.R01.S.doc Version 5.2 Page 23 inspected satisfactory. The home has an up to date fire risk assessment, which has been assessed by the Fire Authority. DS0000028058.V330969.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 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 3 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 DS0000028058.V330969.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. Refer to Standard YA6 Good Practice Recommendations It is recommended the Home develop as a priority the individual Person Centred Plans for service users, these need to be presented in a format that is both preferred and understood by the service user. It is recommended the Organisation review its Care plan format to ensure it is a workable and living document that can be easily referred to by staff. 2. 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