Inspection on 28/03/07 for Victoria Court (Community Therapeutic Services Limited)

This inspection was carried out on 28th 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

Victoria Court (Community... 03/09/07

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The Vicarage

St George`s

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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 Victoria Court (Community Therapeutic Services Limited) 1 Victoria Park Weston-Super-Mare North Somerset BS23 2HZ Lead Inspector Nicola Hill Unannounced Key Inspection 28th March 2007 09:30 Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.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 Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.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. Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Court (Community Therapeutic Services Limited) 1 Victoria Park Weston-Super-Mare North Somerset BS23 2HZ 0845 0943233 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) www.cts-homes.co.uk Community Therapeutic Services Ltd Dr David Wing Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service may provide personal care only, for up to six persons who have a learning disability and/or a mental health difficulty aged 18 - 65 years. New service Date of last inspection Brief Description of the Service: Victoria Court is a two-storey Victorian property that is set above the town of Weston-super-Mare offering views across the seafront and bay. It offers homely accommodation for up to six residents. In addition to provided therapeutic space, it is in easy walking distance of all local amenities. The home is registered with the Commission for Social Care Inspection for people between the ages of 18 to 65 years old and registration category is for people with learning disabilities who may also have mental health difficulties. The service is available to both male and female resident; all rooms are single and have ensuite facilities. Service users needs are met through therapeutic interactions, which respect service users dignity, individuality and privacy and support their rights as individual citizens. There is an experienced staff team on duty over the 24-hour period and access to expert clinical support from consultant psychiatrists. The aim of the home is to support service users through a therapeutic programme toward integrated social living and greater independence. Fees are negotiated on an individual basis according to presenting need. Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of this home was undertaken by the inspector with the service providers, David Wing who is the registered manager, and Emily Bladon who is the responsible individual. At the time of the inspection the home had only been operational for approximately two weeks and had one person in residence. The evidence for the report was gathered from the documentation that the directors had put in place for the running of the home. The inspector also assessed areas of service provision where policy and procedures had been implemented namely the preadmission and admission processes, care planning, staff deployment, training and staff recruitment. The resident at the home was not involved in the inspection and therefore did not contribute to the inspection process on this visit. The evidence which informed the report is limited however, the service aims and objectives have been supported by the investment the service providers have made in staff training and recruitment and the physical environment of the home. The service quality rating from this visit has been assessed as adequate with potential to provision of a high quality service. What the service does well: The service providers have provided very clear documentation which informs potential service commissioners about the purpose of the home; the accessible service user guide complements the statement of purpose and information is also accessible at the website. The service is intended as specialist provision to support people with learning disabilities and mental illness. They have recruited a large staff team who are experienced and well qualified to meet the challenge. The directors have invested in training for the team prior to the home being operational so that there is consistency in approach from the staff team. The physical environment of the home has been planned so that it is family type accommodation whilst allowing for residents to have personal space. The bedrooms are large enough for residents to have additional personal items such as sofas and audio visual equipment without being cramped. All of the bedrooms are ensuite with additional bathrooms available to suit personal preference. The communal areas of the home provide large and spacious areas that have been comfortably furnished. The residents will also be able to access Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.R01.S.doc Version 5.2 Page 6 the kitchen area, and the outside space has been developed so that it can be multipurpose. The service providers have been proactive in seeking out and establishing networks of support to the benefit of service users. For example, they have identified the potential for education at the local college and have made contact with People First to ensure that the future residents at the home have access to advocacy services. 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. Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.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 Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.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): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides information that is specific to the service offered; it clearly says that the objectives and philosophy of the service supported by a service user guide that has been produced in an accessible format. EVIDENCE: Victoria Court in newly registered, and has produced the essential documentation for the service to be registered with the Commission. The documentation is comprehensive of a very good quality, and includes all the information required by regulation. The service user guide has been produced using a Widget programme, so that information is available in a written and pictorial format. This is to aid service users to make an informed choice and understand about the services offered at the home. To date there has been only one admission to the home and the service providers have been unable to assess how successful the pictorial form of the service user guide had been. However, they are prepared to present the information in a variety of formats, for example, they will produce a recorded version of the guide for those people with limited literacy skills or visual impairment. The inspector also suggested that it may be possible in the future to produce a short DVD of the home, which would show the facilities available, where it is in Weston-super-Mare, and have a narrative which tells a potential resident what to expect from the home. Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.R01.S.doc Version 5.2 Page 9 The manager will assess prospective service users to the home prior to admission. This assessment is comprehensive, and the manager will use a variety of assessment tools in order to obtain relevant information which will allow him to make the decision as to whether the home may meet the prospective resident’s identified needs. At present there is only one resident at the home, and although best efforts were made to obtain all relevant documentation and particularly risk assessments, the service providers are aware that not all information was forthcoming about this resident from the previous placement. The manager understands that it is his responsibility to obtain information and not the responsibility of the previous home to provide it. This may be an issue in the future, but the manager is able to adapt his own approach and strategies in order to obtain the necessary information. The service user currently at Victoria Court did not get the opportunity to go through the admission procedure as stated in the statement of purpose, as the placement was urgent. The next planned admission to Victoria Court will take place in mid April, and the manager is aware that this admission will be very different in that it will be planned. The potential service user has already visited the home on several occasions and made informed choices about their bedroom, potential leisure activities to explore when at Weston-super-Mare, and options available for further education. The inspector advised that any visits from prospective service users should be recorded in resident’s file, as this would provide evidence that the home are implementing their policy and procedure for new admissions. Currently there is a written contract available in the statement of purpose that contains all relevant legislation. The contract contains all the information necessary and as listed by the regulation; it ensures that both parties to the contract are aware of the conditions of residency, and any period of notice needed to be given by either side. The majority of placements at Victoria Court are expected to be funded by either local authority or health authorities, which will provide their own financial contract. It important for the home to make sure that the reasons for additional fees are clearly identified in the contract. The inspector discussed with the service providers the possibility of including an accessible contract in the service user guide. It may be possible to have additional information in the back of the service user guide stating that the resident has either read the guide or had it explained to them by a member of staff, so that they understood and agreed the terms of residency outlined in the guide. Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a strong belief that it is essential to involve residents in the planning of care that affects their lifestyle and quality of life. EVIDENCE: The resident currently at Victoria Court had two files, one containing a clinical based formal care plan, and the other containing a person centred plan. The formal plan that has been compiled by the manager, professionals and family members involved with the service user. The plan identifies clinical need and interventions which may be effective to meet those needs. However the resident has only been at the home for a very short period of time, and the interventions and plans in place will be subject to continual review until the needs are fully identified. The plan also has capacity for interventions to be monitored. The formal care plan file is indexed and structured so that all the information necessary for the support for the client is in one place, for example the file contains the assessment and plan, risk assessments, intervention plans, ABC monitoring sheets, and daily records. The success of the system Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.R01.S.doc Version 5.2 Page 11 will be assessed at a later date, however, the providers are keen that all information is accessed by staff, and used to benefit the resident and so impact on the support they receive at the home. The person centred planning documentation is adapted from the essential lifestyle planning and is intended to be completed by the resident possibly with the help of the key worker. At the time of the inspection, the person in residence was not engaging with staff, and not wishing to complete the person centred plan, however, the resident is able to self advocate and make their needs and wishes known. With to respect consultation and involvement of service users, this will be reliant on the service users wishing to be consulted and be involved in the dayto-day running of the home. For the future there is a procedure in place whereby any plans will be discussed with residents, and that at house meetings, residents will be involved in reviewing and developing policy for the home. It is intended that service users will be involved in interviewing new staff after a period of support and training. The manager was able to show the inspector the risk assessments that had been carried out on the current resident at the home. The documentation was very in-depth and provided a safe system of work for staff to follow whilst working with this resident. The risk assessments are linked to the formal care plan, however the personal support plan for the resident has yet to be completed but will support risk taking in pursuit of personal lifestyle choices. The service providers have devised a consent form to be used by resident to ensure that they are aware that information about them is held at the home. The service users are able to access their files and will be supported with giving consent about sharing information with others. In respect of confidentiality, it should be noted that some of the service users who may be admitted to Victoria Court might not be able to give informed consent. The Mental Capacity Act 2005 was discussed with the service providers, and they are fully aware of the implications of the act for residents. Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.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 adequate. This judgement has been made using available evidence including a visit to this service. The inspector was unable to make a full assessment of the outcomes for service users for these standards. EVIDENCE: The key standards for this section would normally be assessed with service users and the record of implementation of an individuals person centered plan. As the home only has one service user who has only been there for a very short time this section cannot be fully assessed on this visit. The intention of the service providers at the home is that service users are supported to access the immediate community, which supported to engage in appropriate leisure activities available around the local area. The service providers have also made inquiries as to the availability of educational courses for a potential resident within the Weston-super-Mare area. Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.R01.S.doc Version 5.2 Page 13 Due to the small number of service users at the home, the menu planning can be flexible to suit individual taste. There is potential in the future for the employment of a cook/domestic at the home, however, as part of their therapeutic programme service users will be enabled to plan and prepare meals. Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.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. The statement of purpose details the specialist treatments the home can deliver and refers to the skills and ability of the staff group. EVIDENCE: The inspector was unable to assess standard 18 fully as the resident at the home was not available to take part in the inspection process. However, from the daily records, it was demonstrated that the home responded to stated personal preferences relating to staff support for personal care. The assessment process identifies the potential for therapeutic interventions that develop personal skills and strategies for self-care and well-being. The interventions are individualised and may involve the service user in developing coping skills, for example, in anger management. The home has a staff team, which is highly skilled and experienced in psychotherapy, and the intention is that there will be therapeutic opportunities for each service user. The individual resident may keep their own GP and health care providers such as dentists if this is practical. The organisation has links to consultant psychiatrists who may be called on to provide expert advice. Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.R01.S.doc Version 5.2 Page 15 At the time of the inspection, the service providers were in the process of implementing health action planning, and were advised of the local contact for the introduction of health action plans (Valuing People, 2001). Wherever possible service users will be supported to take responsibility for their own medication. The home has planned to use the Boots unit dosage system and all staff have attended the training for this system. At the time of the inspection no service users were taking regular medication, and there was no medication on the premises. The inspector reviewed the policies and procedures relating to medication practice on to discuss with the service providers minor adjustments. Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.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 adequate. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure and satisfactory links with external agencies in respect of adult protection. EVIDENCE: The home has a procedure for dealing with complaints, and have included information about making complaints in the service user guide. To date there have been no complaints made about the organisation or its operation. The success of the complaints procedure can only be fully assessed when it has been used. The inspector discussed with the service providers the local adult protection procedures; staff have received information about adult protection through their training (LDAF and NVQ) but should attend the training provided by North Somerset Council. The service providers are experienced in dealing with difficult situations which may result in adult protection investigations being undertaken. The local procedures have already been accessed because the resident at the home is not engaging with the staff team and is potentially at risk. It is not anticipated that an investigation will be instigated, however, relevant authorities are now aware of the current difficulties. The service providers are aware that should it be necessary to use restraint, then they should notify the Commission. Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.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, 25, 26, 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the residents, the bedrooms and communal rooms are pleasantly furnished, and all bedrooms have ensuite facilities. EVIDENCE: Victoria Court has been refurbished to a good standard and has the facilities and potential to provide a comfortable home for residents. At the time of the inspection only one room was occupied, however the inspector toured the premises and was able to view the accommodation. The ground floor bedroom has been altered so that the service could offer accommodation to a resident with impaired mobility. The communal areas were well furnished and the surroundings reflect the quality of service intended to be provided at the home. There was building work taking place to the rear of the building, where the patio area is being relaid and it is intended that this area may be used for barbecues in the summer, and possibly a vegetable garden. Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.R01.S.doc Version 5.2 Page 18 All of the services i.e. heating have been tested and any remedial work has been undertaken. The staff team currently are responsible for keeping the building clean, and areas of the building, which are being used, were clean and tidy. Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.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 service has ensured that staff within the organisation have received relevant training which is targeted and focused on producing good outcomes residents. EVIDENCE: The standards assessed by the inspector are those which can be assessed through documentation as the team is not fully functioning at present, and cannot be assessed on performance. The number of staff at the home at any one time will be dependent on the number of residents and their needs. Currently there is a minimum of three staff on duty between 7:30 a.m. and 10 p.m., at night there is one waking night support worker, and one support worker sleeping in. In addition to this the manager, David Wing, is supernumerary but available to assist whenever necessary. The out of hours support is from both David Wing, and Emily Bladon. The home is not operating to full capacity, and the staffing level may be subject to review as further residents are admitted. The majority of the senior support workers have an NVQ 2 qualification or equivalent, the number of staff with NVQ two or equivalent exceeds 50 . Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.R01.S.doc Version 5.2 Page 20 The recruitment and selection process for the staff team included a clear job description that has allowed the service providers to recruit experienced staff, several of whom have qualifications in psychology and related disciplines. The inspector was able to see the recruitment procedures for the home and noted that best practice is followed in respect of safeguarding service users. All of the staff have a completed application form, relevant references, and CRB checks. In addition to this the service providers have kept records of interviews and any supplementary questions asked of candidates. There are copies held of staff contracts, all of the staff are subject to a minimum threemonth probationary period. The service providers have a commitment to training and development of staff. They have demonstrated this by ensuring that staff have received suitable training prior to the home opening for example, all staff are working toward the Learning Disability Award Framework induction units. In addition to this staff have completed training in health and safety, challenging behaviour and mental health, and positive response training. Future training plans include NVQ for those staff without formal qualification, and service specific training to meet the needs of service users i.e. awareness of personality disorder, autism. All staff work through an induction that is recorded, and staff are monitored for competence. The individual staff files held copies of training certificates; all staff will have their own individual training and development plan. Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.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 adequate. This judgement has been made using available evidence including a visit to this service. The manager is qualified and has the necessary skills to run home, the service is planned to be user focused and to work in partnership with residents and professionals. EVIDENCE: David Wing has been registered by the Commission as the manager for Victoria Court. Prior to this Mr Wing has worked extensively in the NHS providing similar services, and so is experienced both professionally and with undertaking managerial responsibility. He is working toward achieving the NVQ 4 Management award. Both directors have worked together to produce the policies and procedures for the home, and will be directly involved in the day to day support working with residents through their therapeutic programme. Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.R01.S.doc Version 5.2 Page 22 The intention is that the management style is open and both residents and staff can approach either director for advice or to raise issues as they arise in the home. An example of the open style of management given to the inspector was the management of the staff rota which has been delegated to the staff team and only overseen by the directors. How well this approach is working will be assessed at a later date. The key standard 39, could not be fully assessed, however the directors have procedures in place to monitor the quality of service provision and to ensure that the people who use the service are consulted about how the service has impacted on their day to day lives and how this meets their personal life goals. The health and safety legislation at the home appears to be well implemented with staff receiving statutory training. Universal infection control procedures are in evidence with personal protective equipment and cleaning products available around the home. The COSHH information is in place, as are colour coded mops etc for cleaning purposes. The directors have also invested in a metal storage cupboard for any products that need to be locked away. The environmental health officer has visited the home and the staff and management are aware of the Food Agency Standards and monitoring of practise in the food preparation area of the home. Fire safety is adequately implemented at the home with regular tests and staff fire drills. Accident record indicates one staff incident that has been reported under RIDDOR; the directors are aware of their responsibilities to report incidents to the Commission (regulation 37). Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.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 3 2 3 3 3 4 3 5 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000068448.V328005.R01.S.doc 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X 3 X X X X 3 X Version 5.2 Page 24 Victoria Court (Community Therapeutic Services Limited) 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. Refer to Standard Good Practice Recommendations Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Victoria Court (Community Therapeutic Services Limited) DS0000068448.V328005.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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