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Inspection on 02/11/06 for The Pines (Weybridge)

Also see our care home review for The Pines (Weybridge) for more information

This inspection was carried out on 2nd November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The manager and staff team are committed to providing a safe and homely environment for residents. Residents are encouraged to engage in the daily running of the home and their views are continually sought to improve the service the home provides. This is maintained by listening, and understanding residents. The residents appeared to be contented and happy, however the majority of the residents were unable to communicate therefore it was difficult to establish if the residents were satisfied with their care. Positive feedback was received from one resident who had requested to see the inspector during a staff meeting. Observation by the inspector the residents and staff have a good rapport.

What has improved since the last inspection?

A number of areas have been improved these include the patio, has been extended and new paving slabs have been laid, a new awning has been fitted particuarly for one resident who enjoys sitting in the garden during the warm weather. Door guards have been fitted to a number of doors including some bedroom doors these are now connected to the fire alarm system. New smoke detectors have been fitted. New fire doors have been fitted to all rooms. New floor covering has been laid in the dining area and part of the hallway; new carpets have been laid in the lounge, hall and stairs. A new chair lift has been fitted on the stairs following an incident, which occurred. The proprietor/manager informed the inspector she decided to change the stair lift for safety reasons.

CARE HOME ADULTS 18-65 Pines (The) (Weybridge) The Pines 6 Windsor Walk Weybridge Surrey KT13 9AP Lead Inspector Vera Bulbeck Unannounced Inspection 2 November 2006 10:15 nd Pines (The) (Weybridge) DS0000013747.V317748.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 Pines (The) (Weybridge) DS0000013747.V317748.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. Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pines (The) (Weybridge) Address The Pines 6 Windsor Walk Weybridge Surrey KT13 9AP 01932 842954 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Sathiavathy Jeyarani Nesarajah Mrs Sathiavathy Jeyarani Nesarajah Care Home 10 Category(ies) of Dementia - over 65 years of age (1), Learning registration, with number disability (10), Learning disability over 65 years of places of age (4), Physical disability (1), Physical disability over 65 years of age (1), Sensory Impairment over 65 years of age (1) Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 4 residents may be in the category LD(E) - older people with learning disabilities (This will be a decreasing number as the home intends to provide care for 30-65 year olds) 1 person with a learning disability may have an additional physical disability and/or sensory impairment - LD/SI or LD/PD One person of either gender with physical disabilities aged over 65 years of age. (This will be a decreasing number as the home intends to provide care for 30 to 65 year olds) 1 person with a learning disability may be over 65 years of age and have in addition a sensory impairment and/or physical disability. (This will be decreasing numbers as the home intends to provide care for 3065 year olds.) One named person suffering from dementia, over the age of 65 years. (This will be a decreasing number as the home intends to provide care for 30-65 year olds). The age/age range of the persons to be accommodated will be 30 to 65 years 18th August 2005 5. 6. Date of last inspection Brief Description of the Service: The Pines is registered for a maximum of ten residents who have learning disabilities. There are eight single and one double bedroom. The age range of the residents is thirty to sixty five years; however registered provision is also made for one resident over the age of sixty-five years. It must be noted that this is a decreasing number as the home will only admit the former age range when the older resident leaves the home. The service is privately owed and is situated in a quiet residential area close to local facilities and amenities. The home does not have any parking facilities. The home provides a caring and supportive service and encourages residents to be as independent as practicable within a risk-assessed framework. Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit to be undertaken by the Commission for Social Care Inspection as part of a key inspection. Mrs Vera Bulbeck, Regulation Inspector, carried out the inspection. The registered manager/provider Mrs Nesarajah was present. The inspection took 7 hours commencing at 10.15am and finishing at 17.25. There are currently seven residents living in the home, and all the residents have lived in the home for some time. Six residents were in the home on the day of the site visit. One resident who was at the day centre had requested to speak with the inspector. The resident arrived home at 16.45 and the inspector had the opportunity to speak with the resident. The majority of the residents are over the age of sixty years and the residents are mobile and some are able to undertake light duties set out by the home. The home has a chair lift for the residents, which reaches the top third floor, however, management needs to consider the suitability of residents on the top floor, as there are several steps to the two bedrooms. The home has had installed CCTV in a number of areas around the home including the ground floor entrance area, the first and second floor landing areas and stairs, dining room and lounge. The staff members on duty on the day of the site visit were spoken to and one member of staff commented the home is operating an open management style and the staff team feel supported and work together as a stable team. A full tour of the premises was undertaken. Two care plans and two staff files were inspected. The fees range from £800.00 per week to £900.00 per week. The inspector would like to thank the residents and staff members for their time, assistance and hospitality during the inspection. The service users living in the home wish to be called residents, therefore service users will be referred to as residents throughout the report. What the service does well: Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 6 The manager and staff team are committed to providing a safe and homely environment for residents. Residents are encouraged to engage in the daily running of the home and their views are continually sought to improve the service the home provides. This is maintained by listening, and understanding residents. The residents appeared to be contented and happy, however the majority of the residents were unable to communicate therefore it was difficult to establish if the residents were satisfied with their care. Positive feedback was received from one resident who had requested to see the inspector during a staff meeting. Observation by the inspector the residents and staff have a good rapport. 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. Pines (The) (Weybridge) DS0000013747.V317748.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 Pines (The) (Weybridge) DS0000013747.V317748.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs and aspirations are fully assessed and documented prior to admission and on an ongoing basis in regular reviews. EVIDENCE: Residents are admitted to the home following a full needs assessment, which is undertaken by the registered manager. The registered manager explained that she has a format for assessing residents to ensure the home can meet resident’s needs. This was evidenced by sampling, written records and discussion with the staff on duty. There have not been any new residents placed in the home for some considerable time. There are three vacancies in the home but the placing of a new resident needs careful consideration as the majority of residents have lived in the home for some time. It was noted in resident’s files that a number of risk assessments have been undertaken. Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 9 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 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents’ individual plans are clear and comprehensive including details of needs and goals. They also incorporate known or indicated preferences and choices, and include risk assessments. EVIDENCE: Staff stated that residents are supported to make decisions affecting their lives in a number of ways. Each resident has an allocated key worker, who is trained to offer one to one support and who knows the resident well and understands his or her needs. The residents confirmed this during discussions. The majority of residents are unable to communicate therefore staff have the experience to enable residents to make decisions and choices, for holidays, menu planning and outings. For example one resident stated he is able to speak at staff meetings and make suggestions and also informed the inspector if he is not happy about anything in the home he immediately speaks with the manager who always listens and takes appropriate action. Resident’s individual choices of meals were recorded on their weekly menu plan. Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 10 Staff advised that information is provided to residents to assist with decisionmaking and this is in a format to suit their individual needs. All residents are involved with their care planning and indicate they agree with their care plan. Residents who are unable to hold a key to their bedroom, care plans are documented to include the reasons for not holding a key. One resident is able to visit his sister in Suffolk at least four times a year. Staff drive him to Victoria station and he travels by coach on his own and is collected the other end by his relative. The resident informed the inspector he is very pleased to be able to visit his sister as she would not be able to visit him. He also stated that she is very good to him. Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents have opportunities for personal development and to take part in appropriate activities within the home and in the local community. They are supported and enabled to maintain and develop appropriate personal and family relationships. Systems are in place to ensure that residents’ rights are respected. EVIDENCE: Residents are supported to make choices in their everyday lives as far as they are able. Families of residents are consulted and encouraged to be involved in the decision making process. The inspector advised the staff on duty to involve an advocate for those residents who do not have any family or friends. The majority of residents attend various activities, these include visiting the library, going to the pub, leisure activities and one resident goes to church on Sundays with a member of staff. Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 12 Five residents and three staff went to Blackpool on holiday in May for four days. Three residents went to the flower show at Hampton Court Palace and afterwards had a picnic in bushy park. A number of residents are going to see the Christmas lights in London. Residents are able to use public transport with a member of staff and regular shopping trips are organised. There is considerable involvement with the local community. The residents like to go ten pin bowling as well as various other activities. Including going to the local church when they choose to do so. One resident has a key to his bedroom and when he goes out he locks the bedroom door. Residents informed the inspector that they are involved with the menu planning and eat healthily. Food intake and nutritional content is monitored and all residents are weighed monthly. Comments from residents regarding food were very positive and those able to communicate indicated they enjoy the food. The home has a quality assurance system in place to gain feedback from residents and their families. All members of staff receive training at induction on respecting and promoting the rights of residents and all residents are registered to vote. Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance is planned and was seen in care notes, to be provided, where needed, in a respectful and sensitive manner. However, reference to personal hygiene items need to be documented appropriately. Sound policies and practices are in place for the administration and management of medication. EVIDENCE: The inspector was informed by a resident they are able to choose when to go to bed and when to get up and are supported to choose their own clothes, hairstyles and other aspects of personal grooming. The inspector was informed that a key worker cuts a residents hair, this is a preference by the resident. There are weekly visits by the local G.P and residents have an annual health check. All residents have had a flu jab and the community psychiatric nurse from the PCT visits on a regular basis to support one resident. All residents have good support from the medical team as well as other professional health care people, including the dentist, optician, chiropodist and physiotherapist. Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 14 The system for medication administration was seen and was generally carried out to a high standard. The Medication Administration Record (MAR) sheets were seen and no gaps in the recording were noted. Staff stated key workers, who report in turn to the registered manager, monitor the MAR sheets. Any recurring gaps or errors would be referred to the manager, and this would be discussed at a supervision meeting. It was pleasing to see that guidelines are in place for medication that is given “as required”. A photograph of each resident is provided with the MAR sheets to guide staff to the correct resident and a medication information sheet gives details of the medications for each resident. Staff stated that any additional entries to the MAR sheet, which have been handwritten on, are signed by the member of staff making the entry and by a second member of staff who checks that it is correct. This had been carried out. Two staff sign the MAR sheet for all medication given and for the receipt of medication into the home. Sample signatures of all staff that administer medication were held with the MAR sheets for ease of reference. It was also noted that an entry in one of the residents care notes regarding medication stated, “dirty nappy pads”. Management of the home needs to ensure staff refer to personal hygiene items used, are documented appropriately. Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. All required policies, procedures and practices are in place to ensure that residents are safeguarded, as far as reasonably possible, from harm or abuse. However, there is a need to update the complaints procedure policy. EVIDENCE: There were no recorded complaints; the registered manager informed the inspector there were also no external complaints received. Records seen indicated that complaints would be responded to within the guidelines. The homes complaints procedure for residents is in pictorial form and some residents would be able to use it when necessary. The complaints form is written with widget symbols and easy for residents to understand. Each resident has a copy in his or her bedroom. All relatives have also received a copy of the complaints procedure. It was also noted that the complaints procedure needs updating Two new members of staff have to complete the training for vulnerable adults. The registered manager confirmed that she would undertake the training for the two new members of staff. Staff spoken to, stated that they had undertaken training in the protection of vulnerable adults and would report any concerns they had to the manager. Staff said they would be willing and able to report any concerns and “would go to any level to protect residents”. Resident’s finances are paid directly into their bank and fees for their placement is deducted by direct debit. The manager, manages any personal Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 16 allowance money and relatives are involved. All residents have a safe in their bedroom for keeping valuables or medication if necessary. Pines (The) (Weybridge) DS0000013747.V317748.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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. It is accessible, safe and well maintained. The home was found to meet residents’ individual and collective needs in a comfortable and homely way. EVIDENCE: The premises were found to be clean and hygienic, all staff to be congratulated on the cleanliness of the home. All areas in the home have had paper towel dispensers fitted, to ensure the risk of cross infection is eliminated. The majority of residents have their own bedroom; there is one shared bedroom. Bedrooms had been made personal with pictures and posters, televisions, music and radio facilities and individual bedding and soft furnishings. Bedrooms were seen to be of a good size. One resident showed the inspector his bedroom, of which he was justifiably proud. It is pleasing to see that each room is individually decorated and residents are supported to choose the colour schemes to suit their preferences. Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 18 The vacant rooms will be re-decorated in a choice of colours by the prospective new resident. There were a few minor areas that require attention, these include a restrictor on the window of a resident’s bedroom on the top floor and the door was off the hinges of a resident’s wardrobe. The registered manager informed the inspector this has already been reported and is currently waiting for the maintenance person to repair the wardrobe door. It was also noted that the cover was off a light in a bathroom, the maintenance person arrived on the day of the inspection to purchase and fit a new cover. The communal areas of the home consist of a lounge which seats approximately ten residents, and a separate dining room and kitchen. It was noted that CCTV cameras have been installed around the home; the areas currently covered by the cameras are the lounge, dining area, hallway, and first and second floor landings and stairs. The garden to the back of the house is very pleasant and well maintained, this has been re-laid recently. A new patio area has been built and residents are able to sit under the new awning out of the sun. The front garden is very small but nicely laid out. Pines (The) (Weybridge) DS0000013747.V317748.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 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All interactions observed between staff and residents evidenced a high degree of respect. Staffing is kept under review and provided to meet the needs of the residents at all times. EVIDENCE: It was pleasing to note that staff have a good understanding of the residents needs, are respectful and have a good rapport with the residents. On the day of the site visit two staff were new in post one had only started work the day of the visit, Both staff are qualified nurses in the Philippines, and both stated they enjoy working with the residents, the inspector was informed they are under the supervision of the registered manager. Staff recruitment files are up dated and contain all the relevant documents as detailed in Schedule 2 of The Care Homes Regulations 2001. All staff has had a criminal record bureau (CRB) check and Protection of Vulnerable Adult (POVA) check prior to starting work in the home. It is imperative that up dates to CRB are undertaken. The registered manager to ensure all staff has a copy of the General Social Council & Care, code of conduct document. Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 20 A number of staff have completed NVQ Level 2 & 3 and the new members of staff who are qualified nurses will commence NVQ Level 3 in the very near future. Staff has undertaken a number of courses and the majority are up to date with all other mandatory training. Staff supervision was seen to be undertaken on a regular basis, and staff are provided with a copy. The management of the home needs to produced a training programme, to enable management to identify when staff require up dates to their training. A number of training courses have been undertaken and all new staff receive an induction programme, which is covered over several weeks. Any specialist training required by staff is considered by the management of the home. There is one member of staff on waking night duty and one staff member sleeping in. The rota indicates the designated member of staff administering medication. Pines (The) (Weybridge) DS0000013747.V317748.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 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management approach in the home provides an open, positive and inclusive atmosphere. The home has a quality assurance and monitoring system in place that is based on seeking the views of the residents. EVIDENCE: The registered manager is qualified, experienced and competent to manage the home and has completed the registered manager award. The home has an effective quality audit monitoring system in place. The registered manager/provider completes a regular inspection on the home three times a week. The home has produced a yearly residents/relatives survey in pictorial form, to establish if improvements can be made to the home. There were fifteen comment sheets sent out and eleven returned. The comments were positive. There was a letter on file from a relative whose son had Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 22 recently died. The letter was very complementary about the staff and management of the home. The resident spoken to on the day of the site visit was very complimentary about the home, he stated the manger is “very helpful and understanding nothing is to much trouble”. He also said the staff are really good and he is able to speak with any member of staff, particuarly if he has a problem and it is always sorted out. The records observed on the day of the site visit were found to be well documented and kept up to date. This included certificates for the testing of Legionella, gas, electrical and a number of other areas tested. The management of the home has had all new fire doors fitted. The secretary working in the home is involved with the records maintained in the home, as well as ensuring staff records are kept up to date. It was disappointing to find disinfectant and other cleaning materials left in the laundry unlocked, the COSHH cupboard is situated in the laundry, which was locked. However, the hazardous substances were removed to the COSHH cupboard immediately. Staff need further training to ensure they are aware and understand the importance of COSHH regulations. Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 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 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 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X X 3 X X 2 2 Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 24 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. 1 2 3 Standard YA22 YA24 YA24 Regulation 17 13 23 Requirement Complaints procedure needs updating. A restrictor required on a bedroom window on the second floor. The use of CCTV cameras to be reviewed. Timescale for action 08/12/06 08/12/06 08/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA35 Good Practice Recommendations To produce a training plan. Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Pines (The) (Weybridge) DS0000013747.V317748.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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