Inspection on 31/08/05 for Vitalise Sandpipers Centre

This inspection was carried out on 31st August 2005.

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

Vitalise Sandpipers Centre 17/12/09

Vitalise Sandpipers Centre 20/03/07

Vitalise Sandpipers Centre 09/03/06

Vitalise Sandpipers Centre 16/02/05

Vitalise Sandpipers Centre 29/06/04

Vitalise Sandpipers Centre 11/01/04

Similar services:

Ruskin Lodge

Dystlegh Grange

The Good Companions

Springfield Cottage

Cuerden Grange Rest Home

Cornmill Nursing Home

Sue Ryder Care Birchley Hall

Wyncourt

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

CARE HOME ADULTS 18-65 Sandpipers The Fairway Southport Merseyside PR9 0LA Lead Inspector Claire Lee Unannounced 31 August 2005 st 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 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 Stationary 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. Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sandpipers Address The Fairway Southport Merseyside PR9 0LA 01704 538388 01704 549764 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Vitalise Mrs Sheena Paterson Mr Darren Holloran Care Home 36 - Dementia (E) - Dementia over 65 - Physical Disability (E) - Physical Disability over 65 Category(ies) of DE registration, with number DE of places PD PD Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 36 PD and up to 36 PD(E) 2. Maximum no. registered - 36, of which up to a maximum of 22 N (nursing) 3. Service users to include up to 36 DE and up to 36 DE (E) Date of last inspection 16th February 2005 Brief Description of the Service: Sandpipers is a 36-bedded centre run by Vitalise. Vitalise is a national charity providing planned holiday breaks for guests with physical disabilities and planned breaks for carers (for the purpose of this report the term carer refers to a family member or friend who has accompanied a guest to the centre).Sandpipers is located in Southport close to the town centre and with easy access to public transport and the beach. The centre also overlooks the marine lake. Sandpipers is situated over the ground and first floor, the upper floor is accessible by stairs, covered walkway and spacious passenger lift. The centre has a balconied sun terrace, 2 lounges, dining room, bar and other recreational space with chairs on each floor. Sandpipers has 28 single rooms and 4 double rooms. En-suite facilities are also available. The centre has an excellent standard of equipment and enironmental adaptations suitable for guests with disabilities howver staff do ensure maximum indpendence is promoted. The centre continues to meet specialised nursing needs and at the same time provides a relaxed holiday break with a full range of social activities and events within very pleasant, comfortable accommodation. Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 2 days for duration of 8 hours. It was an unannounced visit and conducted as part of the regulatory requirement for care homes to be inspected at least twice a year. A partial tour of the building was conducted. A selection of care, staff and the centre’s records were viewed. The manager and deputy manager were present during the visit and in addition discussion took place with 4 staff, 5 guests and a carer/relative. Satisfaction comment cards were also given to residents and relatives to complete at their leisure. Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 Page 6 What the service does well: Vitalise gives “ visually impaired and disabled people a real choice of holidays, provide vital breaks for carers and inspirational opportunities for volunteers”. Guests come to the centre unaccompanied or on occasions with their carer. Carers can be involved as much as they want with the care and they are also able to relax and enjoy the centre’s facilities. Sandpipers offers a variety of themed weeks for the guests and carers, for example, Queen Week, Racing Week, Youth Week, Garden Week, 30-45’s Week, Alzheimer’s Week, Multiple Sclerosis Week, Holistic Week, Scottish Week, Christmas Shopping Week and New Year Week. Many guests return each year for the same themed week and they were complimentary regarding the social arrangements made on their behalf. On this occasion the centre was holding a youth week and many of the guests were on a trip to Chester Zoo. The centre has its own transport with designated drivers. Staff accompany guests on the trips and where possible the centre aims to provide a volunteer on a 1 to 1 basis; a registered nurse accompanies guests with nursing needs. Guests discussed the trip planned to the Trafford Centre and reported that all the excursions are very well organised and great fun. The lounge has a licensed bar, video, wide screen television (with cable channels) and a disco unit. A band formed by members of staff provides live music regularly. The centre has a swimming pool and guests have use of computers with Internet connection. The centre’s accommodation is maintained to a high standard. All areas were clean, bright and well decorated. The lounge and dining room are spacious and comfortable armchairs are provided by the bar area. There is ample room for wheelchairs and the centre has been adapted to ensure guests maintain their independence. Disability equipment is provided throughout, guests confirmed that the standard of equipment was excellent and staff were proficient in its use. During January each year the centre is closed for cleaning, maintenance decoration and staff training. Guests needs are identified prior to arriving at the centre and a further nursing assessment is completed by a registered nurse. As much information as possible is also obtained from other professional sources to ensure care needs are identified. The care files are organised, easy to read and care plans are updated to reflect the care and treatment given during the guest’s stay. Care files viewed clearly identified potential risks, dependency levels and standard of disability equipment required. Staff interviewed were very knowledgeable regarding the guests’ clinical and social needs. Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 Page 7 Staff receive a good standard of training to ensure they are competent in their role. When the centre is closed each January staff attend training in safe working practice areas and care staff study basic nursing skills. Volunteers are also able to attend workshops. A volunteer discussed her stay at the centre and was enthusiastic regarding the management, the facilities and holiday atmosphere, which she felt was so important. She stated, “the staff are very good and well trained.” 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. Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 There was a good standard of assessments enabling the centre to be sure of meeting the care needs of the guests. EVIDENCE: Assessment details are first collated prior to the commencement of the holiday. The information is provided by the guest and/or their carer when completing a booking form. The booking form asks for details regarding social and nursing needs including information as to the extent of physical disability or sensory impairment, equipment required, preferred methods of communication and general health. All guests are required to have a medical certificate from their GP confirming their care requirements and medication. This was evidenced in the files viewed. On arrival at the centre staff then undertake a further needs assessment and this information is transferred to the plan of care. Assessment documentation from other professional bodies was seen and this included, GPs, social and community based services. A carer who was visiting for the first time reported that the assessment process worked well. Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 and 9 Health and personal care needs of the guests are planned for and set out in an individual plan of care. Guests are fully involved with their care and decide how they wish to spend their time at the centre. They are encouraged to maintain their normal lifestyle. EVIDENCE: Guests have an individual plan of care, which is drawn up with their agreement. Care files seen were organised and easy to read. Care plans recorded key areas such as mobility, communication, personal hygiene, nutrition, pressure relief, skin care, sleep and social support. Clinical needs were also recorded with particular reference to each guest’s disability and range of equipment required to maintain their normal lifestyle. The Traffic Light System is used for assessing manual handling requirements; red, yellow and green denote the level of assistance required. The care files evidenced a daily written record by the registered nurses and guests confirmed that they were advised of any change to their care or treatment. A guest reported, “the care is just excellent and the staff are so capable.” The centre’s GP holds a surgery each Monday and an ‘out of hours’ service is also available. Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 Page 11 Guests are encouraged to relax and have fun at the centre, to maintain their normal lifestyle and join in with the social arrangements. A guest stated that this was the best part of coming to the centre. Staff are however available to provide personal care and to offer advice and support. Guests were going out on a trip to Chester Zoo during the morning but some had chosen to stay at the centre and relax. A guest reported that he often gets up late and it is never an issue for staff. The atmosphere seemed very relaxed. Many guests arrange to meet for the same weeks each year and strong friendships ensue. A guest stated, “the centre is just excellent, you could not have a better holiday.” Staff encourage guests to “do as they want” and to get the most out of the time spent at the centre. Care files viewed recorded potential risks and any restriction to freedom and choice is noted and discussed in detail with the guest and/or carer. Sandpipers is however a holiday centre therefore staff ensure the guest’s normal routine and their level of independence is understood and respected. Risk assessments were viewed for manual handling requirements, use of bed rails and disability equipment. The centre has a reception area and guests are asked to sign in and out of the building. A carer commented on the very good security system and that the centre felt safe. Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13,14,15,16 and 17 Guests enjoy the freedom of the centre. They are able to come and go as they wish and join in with the social events organised by the centre. They are able to visit independently or with a carer and are encouraged to maintain their normal lifestyle. Meal times are a social occasion and guests are offered an excellent choice of well-balanced meals. EVIDENCE: Sandpipers offers a range of themed weeks for the guests. This includes, Queen Week, Racing Week, Youth Week, Garden Week, 30-45’s Week, Alzheimer’s Week, Multiple Sclerosis Week, Holistic Week, Scottish Week, Christmas Shopping Week and New Year Week. On this occasion a youth week was being held and guests were complimentary regarding the social events that were organised. Guests arrive with or without their carers therefore numbers present at the centre can fluctuate. The entertainment board is situated on the first floor and is written in a suitable format. The centre has its own transport and trips out are arranged most days. Discos, live music and parties held in the evenings. Some guests had chosen to go to Chester Zoo, Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 Page 13 while others were shopping in Southport or had remained at the centre. Staff and volunteers were observed spending time with guests, chatting and playing chess. The lounge has a licensed bar, video, wide screen television (with cable channels) and a disco unit. A shop is situated in the main reception hall however many guests go into Southport shopping with their volunteer. Guests and their carers can use the swimming pool and the centre offers a full range of services including hairdresser and massage. A guest was looking forward to the trip to the Trafford Centre and the night out in Manchester with the staff. It was evident that the guests enjoy being together and several stated that the social side of the centre was “just brilliant.” Many guests come unaccompanied to the centre or with their carer. Carers decide how much they wish to be involved with the care or they can take a break and enjoy the centre’s facilities. A carer stated that she was very reassured by the staff’s professional approach and was happy with the care. On occasions married couples stay at the centre. Guests are able to lock their room if they wish and they are also provided with a lockable facility for money and valuables. A carer reported, “the centre feels very safe and I have no worries about leaving belongings in my room.” The guests use the balcony overlooking the marine lake and the grounds are accessible for wheelchairs. The rear gardens are currently being landscaped. All areas of the centre are accessible and a guest reported, “as the centre is so big, it never seems crowded.” The menu was displayed on each dining room table and guests were very complimentary regarding the catering. A choice of 2 hot meals is provided at lunch and dinner and guests and carers can enjoy wine with their meals. A salad bar is always available and users are offered a vegetarian selection and cooked breakfast. Special occasions are celebrated and party nights catered for. The licensed bar is open at various times and staff receive bar training as part of their induction. Snacks and hot/cold drinks are available and there is drinks machine. For the trips out from the centre picnic lunches are provided. Comments regarding the food included, “brilliant”, fantastic choice”, “too much to eat”, “good service from the staff”, “just as good as being in a hotel” and “great chef.” It was evident that the excellent standard of food contributes to the guests time spent at the centre. The chef undertakes food hygiene training with the staff. Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 General support and health care needs are managed by staff to ensure maximum independence and to maintain the guests’ privacy and dignity. Guests’ care needs are reviewed to monitor any change in condition or treatment. Medicines are administered according to the centre’s policy and procedure and this includes self-medication. EVIDENCE: The centre carers for guests with multiple complex nursing needs and those who need personal support. Care is provided according to individual needs and staff interviewed were knowledge regarding care delivery. A number of guests reported that the standard of care was very good. With regards to dependency levels and assessing any potential risk, information is collated when guests and/or carer complete the initial booking form and then a further assessment is undertaken when the guest arrives at the centre. Manual handling needs and instructions to staff were clearly stated in the plan of care. A guest said, “the staff are very capable when using the equipment.” Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 Page 15 Many guests require wound care and a care file viewed evidenced a detailed record of the affected site and treatment. Guests come to the centre with their own prescribed dressings however the centre also has a well-equipped clinical room. The centre provides a GP service once a week and this is conducted in the nurses’ surgery or in the privacy of a guest’s bedroom. Staff are also able to contact the out of hours GP on call service and A&E department of Southport Hospital. Any changes made to the plan of care are documented and GP’s and other health professionals are advised of these changes by letter when the guest returns home. A number of medicine administration sheets were seen and these were completed to a satisfactory standard. Guests who wish to self-medicate may do so and they are provided with a lockable facility in their rooms for the safe storage of the their medicines. Guests bring their own medicines to the centre; these are counted in, entered on individual medicine sheets and counted out when they return home. A small portable lockable container is used for transporting the guests’ medicine when out on trips from the centre and these are recorded in a portable medicine file. All staff receive safe medicine awareness training. Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 Complaints are handled properly to provide guests with confidence that their concerns will be listened to, taken seriously and acted upon. EVIDENCE: The centre has a complaints procedure and the general manager or the care manager investigate complaints received. Guests interviewed had no cause for concern or wished to make a complaint. All stated that staff were approachable and they could discuss anything that was troubling them. Since the last inspection the centre has received 9 complaints, 7 have been resolved and 2 are being investigated. Staff and volunteers stated that guests voice their concerns and management are good at dealing with issues that arise. Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,30 The layout and location of Sandpipers is suitable for its stated purpose and the centre provides very comfortable, clean, well-maintained accommodation. EVIDENCE: Sandpipers is a purpose built centre situated near the sea front with easy access to the town centre. The centre provides excellent accommodation and furnishings, fittings and equipment are suitably adapted for guests to maximise their independence and to maintain their normal lifestyle. A guest stated that the centre achieves this aim. The centre is situated over the ground and first floor; the upper floor is accessible by stairs, covered walkway and passenger lift. The centre accommodates wheelchairs, corridors are wide and handrails are placed throughout. The second floor of the building provides accommodation for volunteers. The centre has a balconied sun terrace, swimming pool, 2 lounges, dining room, bar and comfortable seating on each floor. There are 28 single rooms and 4 double rooms. En-suite facilities are also available and bathrooms/toilets have a very good standard of suitably adapted equipment. Guests confirmed that all areas of the centre were maintained to a very good standard and that the laundry service was efficient. A door entry system is in Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 Page 18 place at the front entrance for security and guests, carers and visitors are asked to sign in. Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 and 35 The home had sufficient numbers of experienced and skilled staff to meet the needs of the guests. The centre provides a training programme to ensure competency in their role. Some members of staff had not received the necessary Protection of Vulnerable Adult check prior to employment, which is needed to provide protection to people living in the home. EVIDENCE: The general manager confirmed that new staff have been recruited and the centre presents with a stable work force. The duty rota for the centre was seen and this along with the staff diary evidenced numbers of staff on duty. Agency staff are used when a shortfall exists and where possible the same agency staff return to ensure continuity of care. A sliding scale for staffing levels is in place depending on the number of guests staying at the centre. Vitalise relies on a volunteer force and many return each year. Volunteer assist with the social side of the guests stay and experienced volunteers are trained to assist with low dependency personal care. The management carefully monitors this. Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 Page 20 Staff files for 3 new staff were seen. These evidenced completed job application forms with a history of previous employment, 2 written references, health declaration and terms and conditions of employment. A member of staff was previously a volunteer and the centre provided a reference, as a second reference had not been received. New staff are supervised during their induction and until a routine check from the CRB (Criminal Record Bureau) is obtained. 2 new staff however had not received a clearance from the POVA (Protection of Vulnerable Adults) register, which is a requirement prior to employment in order to protect residents from known abusers. This needs to be addressed in all cases of future staff employment. Volunteers and college students are also subject to full police clearance before arriving at the centre. Both staff and volunteers receive a full induction and an induction pack for a new member of the care team was viewed. Induction material is comprehensive and is carried out by the heads of each department over a 6week period. During the month of January the centre is closed for general maintenance and 2 weeks of staff training. Each member of staff has a training log for and the centre provides training in safe working practice and clinical care. Volunteer workshops are also held. It was noted that a member of the care staff required a course in manual handling and this was brought to the general manager’s attention. Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The fire records were in date to promote and protect the health, safety and welfare of the guest. EVIDENCE: The centre’s fire logbook was seen and this evidenced regular checks of fire prevention equipment and fire awareness training for staff. A contact is also in place for checking and testing of the equipment by an external engineer. Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 4 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x 3 4 3 3 4 Standard No 31 32 33 34 35 36 Score x x 3 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sandpipers Score 4 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 Page 23 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. Standard 34 Regulation 19 Requirement New staff to receive POVA Clearnace prior to commening employment Timescale for action ongoing 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 Good Practice Recommendations Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 Page 24 Commission for Social Care Inspection Burlington House Crosby Road North Waterloo, Liverpool L22 0LG National Enquiry Line: 0845 015 0120 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 Sandpipers 20050831 Sandpipers X10023 UN Stage 4 S17270 V247082 F53.doc Version 1.40 Page 25 - 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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