Inspection on 14/11/07 for The Shieling

This inspection was carried out on 14th November 2007.

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

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

Other inspections for this house

The Shieling 30/05/06

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Shieling The Shieling St. Ebba`s Hook Road Epsom Surrey KT19 8QJ Lead Inspector Jenny McGookin Unannounced Inspection 14 November 2007 12:00 th Shieling DS0000066519.V354301.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 Shieling DS0000066519.V354301.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. Shieling DS0000066519.V354301.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shieling Address 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) The Shieling St. Ebba`s Hook Road Epsom Surrey KT19 8QJ 01372 203014 Surrey and Borders Partnership NHS Trust Christine Ann Ephraim Care Home 10 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (1) of places Shieling DS0000066519.V354301.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th May 2006 Brief Description of the Service: Shieling is a large detached property situated within the St Ebba’s Hospital Complex Epsom Surrey. It is currently registered to provide residential care for up to 10 adults with learning disabilities. The accommodation for Service Users is provided on one floor. The communal space is provided in two good size dining rooms and three comfortable sitting rooms. Service users have access to a large enclosed garden, which was laid out in lawns and an area trees at the rear boundary. The home has limited parking space to the front with an additional space provided for the home’s minibus. The current fees for the home are £2,123.72 to £3,395.70 per week. This fee covers residential care; day care; dental services; chiropody; therapy support; medical and surgical supplies (including medication and continence products) as well as care support for 7 day holidays. Additional charges are payable for items of a personal nature. Information on the Home’s services and the CSCI reports for prospective service users should be detailed in the Statement of Purpose / Service User Guide. The e-mail address for this home is: Christine.Price@sabp.nhs.uk Shieling DS0000066519.V354301.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection site visit, which was intended to inform this year’s key inspection process; to review findings on the last inspection (November 2006) in respect of the day-to day running of the home; and to check compliance with matters raised for attention on that occasion. The inspection process took just under seven and three quarter hours, and involved meeting with the manager, a senior support worker, two support workers and a visiting advocate. Consideration was also given to the Annual Quality Assurance Assessment submitted in advance of the site visit by the manager. This was judged a well-written and comprehensive account of the issues raised, which reflected provision fairly. The inspection also involved a tour of six bedrooms and all the communal areas, and the examination of a range of records. Two service users’ files were selected for case tracking. Conversations with the service users were limited in most cases by their level of disability, but interactions between staff and the service users were observed during the day. Feedback questionnaires were issued by the inspector for distribution to service users and a range of other stakeholders, but not in time to include all the responses in the first draft. Any responses received after the final publication of this report will, therefore, be assimilated into the Commission’s own intelligence, for future reference. What the service does well: The location of this home is isolated within a larger site awaiting redevelopment, so it is not ideally suited for its stated purpose but the property itself is being maintained to a very satisfactory standard. The home was tidy, clean and odour free. There are homely touches throughout The service users’ admission to this home was led by funding authorities. However, the work done to support their admission is judged careful and sensitive practice. The social, health and personal care needs of the service users are well addressed, and there is input from a range of healthcare professionals and other specialists as required. Relatives spoken with on the day of this visit expressed a high level of satisfaction with the services provided. Overall, there was a high level of compliance being maintained with the National Minimum Standards throughout the inspection process. Shieling DS0000066519.V354301.R01.S.doc Version 5.2 Page 6 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. Shieling DS0000066519.V354301.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 Shieling DS0000066519.V354301.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 2, 3, 4 The service users and their representatives were well supported with the transfer to this home. The home’s comprehensive preadmission assessments ensure all parties could have confidence that the home would meet the service users’ needs. EVIDENCE: The home has a Statement of Purpose and Service User Guide, which have previously been judged compliant with the elements of the National Minimum Standards. At the time of this site visit, both documents were scheduled for review and will, therefore, be reassessed once this process is completed. Each placement is subject to the terms of a “Support Agreement” issued by Surrey and Borders NHS Partnership, which is renewed annually, and supplemented by the terms and conditions contained within the funding authority’s own placement contracts (currently three county councils). These documents are not within the scope of this inspection. Shieling DS0000066519.V354301.R01.S.doc Version 5.2 Page 9 There is as yet no prospect of a much simplified (e.g. picture / symbol assisted version) of the Statement of Purpose, Service User Guide or contract for the service users. This is recommended, though it is accepted that these service users each have special communication needs, which would need to be separately catered for. The home’s admission process would also benefit by addressing the question whether other languages or formats were warranted in each case; as it would compensate for service users not being able to confirm this independently. There was good information about the extent to which these service users were introduced and supported to settle into this home, which included preadmission visits and the sensitive observation and interpretation of their responses, as well as consultation with other stakeholders (familial and professional). The service users clearly benefited by the continuity provided by the transfer of staff and other service users they already knew. The home is able to demonstrate its capacity to meet the special needs of these residents. Examples are detailed throughout this report. Shieling DS0000066519.V354301.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 6, 7, 8, 9, 10 Service users are involved in decisions about their lives, and play a central role in planning the care and support they receive. EVIDENCE: This home’s care plans are person-centred and are designed to enable each service user’s health, personal and social care needs to be addressed, particularly when these are comprehensively underpinned by charts (weight, diet, behaviour etc), and individualised programmes of activities. Where limitations are in place, these are properly justified by documented risk assessments covering the individual, their activities and environments (on and off site), and consent forms. Records confirm that these plans are being reviewed regularly to respond to any changes. They focus on how the service users can develop their skills and interests, and carefully detail the extent to which staff need to support or Shieling DS0000066519.V354301.R01.S.doc Version 5.2 Page 11 intervene, so that they are practical working tools. Most elements of this process are written in the first person, to keep each service users’ perspective central. There is active support from most of the service users’ relatives and each service user has a key worker, to build up special relationships with them and work on a one to one basis. Staff showed a sound understanding of the importance of service users being supported to take control of their own daily lives, and to make their own decisions and choices. One service user has benefited by long-term input from an advocate, and arrangements are being made to access advocacy services for a second, to ensure the service users’ rights remain central to the operation of this home. Although there was still some reliance on NHS generated documentation (matter raised for attention at the last inspection) and some inconsistencies in the way the records in files were arranged, the home’s arrangements for keeping confidential information secure against unauthorized access were judged satisfactory. Shieling DS0000066519.V354301.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): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Services users benefit by the support they get to make choices about their life style, and to develop their life skills. Social, educational, cultural and recreational activities are judged likely to raise individuals’ aspirations EVIDENCE: Abilities, activities and personal preferences were established as part of the service users’ preadmission assessment process, and developed by their person-centred care planning, day-to-day observations and consultation or interpretation thereon. This home offers support to service users in maintaining or developing their practical life skills (for examples, four can load and unload the washing machine or dryer, and several are supported with cooking and shopping) and Shieling DS0000066519.V354301.R01.S.doc Version 5.2 Page 13 there is a day service on the hospital site where service users have half-day activities such as gardening, cookery and woodwork. There are recreational pursuits on site - such as games, DVDs, dominoes, and Bingo. During the good weather there are occasional barbecues at the home or day service. And recreational pursuits off site include clubs, bowling, horse riding, trips to a garden centre, the cinema, Epsom Play House, the local library, and places of interest (e.g. Richmond Park) i.e. mainstream community activities not confined to or identifiable with disabilities. The home has a dedicated vehicle but most service users have bus passes and are supported to use public transport (buses, trains) and to walk. There are plans to start football matches later in the month. The service users have had long weekend breaks at Centre Parks, and a holiday is planned at Butlins for early December. One goes to college three times a week (for computer training – there is a PC on site too). One goes swimming though staff are hoping to take a few more. Activities are, in each case, properly underpinned by a comprehensive range of risk assessments and specialist input as appropriate. The home maintains records of activities for each individual. Services users were observed being supported to make some decisions and choices during the inspection visit. Some attend church for weekend or seasonal services (e.g. harvest festival, and the home is visited by a vicar and, over Christmas, children for carol singing. There are open visiting arrangements, and there was anecdotal information on the extent to which staff support service users to maintain links with family and friends. There is a telephone line to the office and kitchen, plus one in each sitting room for the service users’ use, and the home also has the use of a mobile phone. Feedback from one source has suggested this system would benefit by a group pick-up facility, as they had sometimes had to ring each of the available numbers to obtain a response. Dietary needs and preferences were also established as part of the preadmission assessment process, and confirmed by the care planning process and day-to-day observations. The home has two dining areas, one either side of the central kitchen, both of which provide congenial settings. No special feeding equipment or adaptations are currently warranted. The inspector joined the service users for one meal and judged it well prepared and presented. Records are kept of options actually chosen by individuals, as required. The inspector was particularly interested to hear about one of the ways this home had celebrated diversity – by each member of staff preparing a different national dish over a week, and by a Diwali Party. Feedback from relatives and staff indicated this had been enjoyed immensely by everyone involved. Shieling DS0000066519.V354301.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): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. 18, 19, 20, 21 The health and personal care that people receive is based on their individual needs. This includes the care required in the event of illness, ageing or death. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The home’s person-centred care planning processes properly assess the extent to which each service user requires assistance with their own personal care, and their choice and control is actively promoted by staff as far as possible. Each service user also has a “Health Action Plan” All the bedrooms are single occupancy and there are enough toilet and personal care facilities to guarantee their availability and privacy. Staff are available on a 24-hour basis to assist service users. Shieling DS0000066519.V354301.R01.S.doc Version 5.2 Page 15 The care planning process routinely addresses a range of standard healthcare needs (opticians, dentist, GP etc) as well as access to consultant psychiatry and other healthcare specialists. Feedback from one healthcare professional included statements like “The staff in this house are very professional and skilled” and, when asked what she thought the home did well, said “Manage people with LD and autism. The people concerned have greatly improved in that their level of challenging behaviour shown has greatly reduced. The staff are always welcoming and are very caring. The relatives of the individuals tell me that they are satisfied with the care”. The medication arrangements (storage and record keeping) were judged compliant with National Minimum Standards, and the home has periodic audits by a pharmacist, to ensure practice conforms to best practice standards – most recently in August 2007 where the overall impression was “very satisfactory”. Staff have had training and have ready access to an up to date British National Formulary on medication. But the manager was advised to keep a copy of the Royal Pharmaceutical Guidance to further underpin knowledge and practice. Since the last inspection, “Best Interest” meetings have been held with the service users’ relatives or representatives, to sensitively establish any special needs in the event of illness, ageing or death. This is judged exemplary practice. Shieling DS0000066519.V354301.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 22, 23 Service users are supported to express themselves appropriately, and the home has a complaints procedure in place. Service users are protected from abuse, and have their rights protected. EVIDENCE: This home has policies on complaints and whistle bowing, although the policy on complaints will need to be updated to take the new arrangements into account, once these become operative. There have been no complaints registered by the home since the last inspection. Feedback indicates that funding issues have caused some sense of inequity among parents, and the future of the hospital site has been subject to campaigning – both of which could usefully have been pursued through the home’s complaints procedure, even though neither issue implicates the home’s practice. The absence of recorded complaints is not generally judged a realistic reflection of day-to-day life, given the special needs and interactions of the service users. The challenge will, therefore, be to find ways of translating expressions of dissatisfaction into recordable events, so that anyone authorised to inspect the records can evaluate the extent to which their responses are listened to and acted on. Shieling DS0000066519.V354301.R01.S.doc Version 5.2 Page 17 There has been considerable input from an independent advocate in respect of one service user, with more in prospect. Feedback from the advocate includes comments like “It is like a home. They didn’t get a homely building but they’ve done their best to make it so. The sitting rooms really are sitting rooms. Staff seem to work with them as friends. Sometimes I don’t think you could tell the difference between the service users and staff. They all look so smart and so well cared for. **** is always so clean and well shaven. His hair is always so healthy. It’s as if someone who is proud of him had got him ready. You can talk to anybody – there is no pushing you out. We have little socials with the parents” and “I have never been so relaxed about ***. I don’t need to phone or check up on things between visits. I feel everything that’s decided for him is right”. The home has an up to date copy of the local authority (i.e. Surrey County Council) Multi Agency Safeguarding Adults Policy. In meetings with the inspector, staff invariably confirmed their commitment to challenge and report any abuse, should it occur. And all confirmed having had training. Shieling DS0000066519.V354301.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 24, 25, 27, 28, 29, 30 The physical design and layout of the home enable service users to live in safety. Service users benefit by this well-maintained and comfortable environment. EVIDENCE: The location of this home (i.e. within a hospital site, which has been awaiting development for some time) is not ideal. There is no site plan at the entrance to the site, and there is no signage to guide visitors around the site. Both are recommended. The grounds are reasonably flat and there are focal points to draw the attention to, and to walk or sit in, plus a network of lanes across it. The home has its own garden area, which is mostly laid to lawn and secured by fences and a locked access gate. Shieling DS0000066519.V354301.R01.S.doc Version 5.2 Page 19 The property itself is not entirely domestic in its design. But its renovation has been carried out with these service users’ needs in mind, and all areas of the home inspected were found to be homely, comfortable and clean. The furniture tends to be domestic in style and there were homely touches throughout, with more in prospect. The home has a “No Smoking” policy. The communal areas (three sitting rooms and kitchen) of this home are spacious. All windows offer pleasant views of the site. The seating in the dining and sitting rooms are appropriate for the service users. The kitchen is light, airy, clean and well maintained. No matters were raised for attention. There are four communal bathrooms (three of which are domestic and also have a WC, and one is adapted) plus a walk in shower room i.e. reasonably accessible to bedrooms and communal areas. No special equipment is warranted other than one non-slip mat for use in one bath, small grab rails on baths and some paddle style cistern handles. No matters were raised for attention. Water temperatures are taken each time service users bath, and are recorded in folders kept in each bathroom. Some service users require more direct support than others. All the service users’ bedrooms are single occupancy and the six inspected were found to be well maintained. Each bedroom was personalised. In terms of their furniture and fittings, they were, however, generally not fully compliant with the provisions of the National Minimum Standards. Non-provision will need to be justified by fully documented consultation and risk assessment. No other matters were raised for attention. All the maintenance records seen were up to date and in good order. Shieling DS0000066519.V354301.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 31, 32, 33, 34, 35, 36 Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service, and to support the smooth running of the service. EVIDENCE: Staffing levels are designed to offer a minimum of four staff during the waking / working day (7am to 2.30pm, and 1.30 to 9.00pm), and two waking night staff (from 8.40pm to 7.10am). There is clearly a flexibility to meet peak periods and special needs (one service user often requires 1:1 support). This was judged an appropriate level of staffing, in the light of information on the assessed needs of the residents; and staffing levels complied with this on the day of this inspection visit. The rapport between staff was judged appropriately familiar and respectful, and feedback from other sources (detailed elsewhere in this report) confirms this was representative. Records confirm a systematic recruitment process, subject to police checks, references, identification and health checks. Shieling DS0000066519.V354301.R01.S.doc Version 5.2 Page 21 Staff are issued a copy of the General Social Care Council standards of conduct and practice as part of their recruitment. This is judged sound practice. Records and staff confirmed that supervision sessions complied with the elements of this standard, both on terms of their frequency and their scope – specifically the home’s philosophy and aims into work with individuals; monitoring of work with individual service users; support and professional guidance; and the identification of training and development needs. See section on “Conduct and Management” for findings in respect of the home’s manager. There is a generally satisfactory level of investment in mandatory and specialised training, though only four out of the fourteen staff are reported to be already accredited to NVQ Level 2 or above. Nine are currently working towards this but funding is not yet available to invest in others. Shieling DS0000066519.V354301.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 37, 38, 39, 42, Service users benefit by the management and administration of the home, which are based on openness and respect for its service objectives. Service users benefit by the quality assurance systems in place but these require further development. The manager is working towards RMA qualification and has the vision and skills to develop the potential of this service to benefit service users and staff. EVIDENCE: The Commission’s registration processes have already established that the manager’s qualifications and experience are appropriate to her role, accepting that she is still working towards RMA accreditation. Christine Shieling DS0000066519.V354301.R01.S.doc Version 5.2 Page 23 Ephraim has properly earned the respect of staff and other stakeholders, and has managed the transition of this service from NHS to social care effectively. The processes for managing the home are accessible, transparent and there are clear lines of accountability within the home and on a larger scale in terms of the regulatory duty of the registered provider (Surrey and Borders Partnership NHS Trust – hereafter referred to as SABP) to carry out its own inspection visits at least once a month. SABP has a two-year business plan (dated May 2006), which usefully summarises its place in the market, the scope of its organisation, its deployment of resources and financial standing. It set key action for each strand of its operation, all of which indicates a business like approach. The challenge will be for this home to produce its own unit business plan to demonstrate how it intends to roll out the corporate business plan. The home clearly places its service users at the centre of its own operations. See section on “Individual Needs and Choices” for details on the way this principle is being applied on a daily basis; and there are opportunities for families, and other stakeholders to give feedback at individual reviews. However, it is too soon to judge the scope and effectiveness of its quality assurance systems on a larger scale. All the service users are male and with one exception (one is of mixed race) white British. The staff group shows more diversity (African and Caribbean, Asian, Irish as well as white British) and shows a balance of genders. There was good anecdotal information about the ways in which other cultures are celebrated – indicating an active commitment to Equal Opportunities. Access to activities not necessarily confined to this client group and community presence are central features of the care planning processes and have been reported on elsewhere in this report. Shieling DS0000066519.V354301.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 3 4 3 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 2 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 4 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 4 12 4 13 4 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 4 4 4 3 X X 3 X Shieling DS0000066519.V354301.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA1 Good Practice Recommendations There should be an adapted version of the Statement of Purpose, Service User Guide and contract for the service users. The home’s admission process would also benefit by addressing the question whether other languages or formats were warranted in each case. 2 3 4 YA15 YA24 YA25 One source has suggested the home’s telephones would benefit by a group pick-up facility There should be a site plan at the entrance and signage to guide visitors around the site, to facilitate their access. Bedrooms. Each bedroom should be checked against the provisions of the National Minimum Standard. Nonprovision will need to be justified by fully documented consultation and risk assessment. The challenge will be for this home to produce its own unit business plan to demonstrate how it intends to roll out the DS0000066519.V354301.R01.S.doc Version 5.2 Page 26 5 YA38 Shieling corporate business plan. 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