Inspection on 28/02/06 for Whitwell

This inspection was carried out on 28th February 2006.

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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Whitwell 12/09/06

Whitwell 12/09/05

Whitwell 08/02/05

Whitwell 28/07/04

Whitwell 16/12/03

Similar services:

Hillside

Applegarth

122 Scorer Street

St Marys Nursing Home

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Whitwell 2a Albert Street Boston Lincs PE21 8PE Lead Inspector Sue Hayward Unannounced Inspection 28th February 2006 10:00 Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 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 Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 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 Older People and 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. Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Whitwell Address 2a Albert Street Boston Lincs PE21 8PE 01205 350946 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) H4037@mencap.org.uk Royal Mencap Society Care Home 6 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (1), Physical disability (3) of places Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 2005 Brief Description of the Service: Whitwell is a detached house in a residential area in the town of Boston. It is owned by the Mencap foundation and provides care for up to six residents three who have learning disabilities and three whose main need is due to physical disabilities, but also have a learning disability. At the time of the visit the home had one vacancy. There is garden to the back and side of the property and an enclosed courtyard to the front. Visitors’ car parking is on the main street. Boston has a range of shops and facilities and the home is close to the towns park. Residents have their own single bedrooms, two that are located on the ground floor. There is not a lift so any residents who have rooms upstairs must be able to manage the stairs. Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second required by law for April 2005 to March 2006. It took place over 4 hours starting at 10:00 a.m. One inspector carried it out. The main method of inspection used was “case tracking”. This involved selecting a sample of two residents and tracking the care and support they receive through checking records, discussion with one of the residents and two staff members on duty and the acting manager. A sample of records and policies and procedures were also checked and a partial tour of the premises took place. This included viewing three residents bedrooms, the lounge, dining kitchen and bathrooms and toilets. In addition one other resident was spoken to during the visit. What the service does well: What has improved since the last inspection? The requirements of the last inspection have been addressed. These related to ensuring that records were available to demonstrate a satisfactory staff recruitment procedure is in operation and locks to bathrooms and toilets were in place to ensure residents privacy when using them, although they still need some adjustment to ensure that they are easy for residents to use. Since the last inspection the home has changed its pharmacy arrangements and staff have had further training in relation to administering medications to help ensure that a safer system is in place. There are plans in place to refurbish and upgrade bathrooms and toilets and whilst there is not a date set yet for this to take place quotations have been obtained. Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 6 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. Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 There is a satisfactory system in place to assess the needs of residents and how they are to be met in the home prior to admission and to ensure that residents are well informed about the home. EVIDENCE: There has been one person admitted to the home since the last inspection. Records demonstrated that there had been an assessment, which had included obtaining information from other professionals such as social workers and the home had also completed its own assessment. Care plans were also in place for both residents’ records checked and contained signatures of residents denoting their involvement with the development of them. Records demonstrated that residents had had important information such as information about the service, complaints procedure and terms and conditions Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 9 explained to them. This information is also available in symbol form to assist with communication and was contained on each of the files checked during the inspection. A resident spoken to confirmed that he liked living at the home and whilst there was difficulty communicating with him verbally, observations made were that staff were able to communicate with him well and there was a good rapport between staff and residents. Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Care plans are drawn up with the involvement of residents if able or their relatives and reflect the individual needs and wishes of residents. Systems are in place to identify and minimise risks whilst enabling residents to be as independent as possible. EVIDENCE: Both files checked contained care plans, which demonstrated that they had been discussed and agreed by residents or their relatives. They were also in symbol form to assist residents who have reading difficulties. Records demonstrated dates of when they were reviewed. Comments from a staff member indicated that care plans were available for staff to refer to and staff had a good knowledge of the needs of residents and how to meet them. For example a staff member was well aware of the social and leisure interests of Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 11 residents’ asked about and this was reflected in the information that the home holds about him. Records contained information about residents’ individual preferences and likes and dislikes. Risk assessments had been completed in relation to matters such as using public transport, manual handling needs and household tasks and the support necessary to minimise any potential risks. Residents meetings are held and it was noted that personal safety in the community had been a discussion point. Staff spoken to gave examples of how residents are enabled to make choices about their lifestyles such as where they choose to go on holiday. Residents’ comments and individual records kept also demonstrated that they have choices offered. Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 17 Residents have opportunities to pursue a range of activities within the local community according to their personal choice. Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 13 They receive well-balanced meals that take into account individual preferences and dietary requirements. EVIDENCE: On the day of the inspection a resident went shopping and was planning to have lunch out at a local pub. Other residents were attending a day centre. Records, discussion with staff and photographs also provided information to demonstrate that residents have opportunities to participate in the local community such as meals out, ten pin bowling using locals shops and are supported to do so by staff. One resident spoken to confirmed that he had chosen to go on holiday to the seaside. Staff comments and observations made during the inspection confirmed that residents’ privacy is respected and they are supported to be as independent as possible such as being involved in domestic tasks around the house if they wish. Comments from residents and records demonstrated that a healthy diet is provided which incorporates residents’ individual preferences. Staff were aware of residents dietary needs and confirmed that if able they can assist with meal preparation. There is some flexibility as to times of meals for example, a staff member said that at the weekend residents can choose to have a lie in and they have breakfast in bed if they wish. The organisation has policies and procedures in relation to food and nutrition and records checked demonstrated that staff had had training about food hygiene. An environmental health officer visited the home on 01/02/06 and made minor recommendations in relation to the kitchen, which the manager confirmed had been dealt with. Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 20 The care needs of people the service supports and their preferred lifestyles is being met. This is supported by the care planning system and staff’s knowledge of individual needs. The systems in place in relation to medication help to ensure residents safety. EVIDENCE: Care records, comments from residents and observations made on the day demonstrated that care is provided according to residents’ identified needs and personal preferences. For example, it was noted that a resident was being accompanied out shopping and was then going to have lunch at a place of his preference. Care plans detailed individual care needs and particular preferences for example in relation to sleep patterns and personal hygiene needs and staff were aware of what these were. There was information Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 15 contained in residents’ files to demonstrate the involvement of other professionals such as occupational therapists and district nurses and friends and family. A resident’s comments indicated that he is supported to be as independent as possible. Some administration errors have occurred since the last inspection however this has been addressed appropriately by making changes to the arrangements for storing and administering medication to ensure a safer system is in place. A staff member gave a good explanation of the procedures for administration and disposal of medications. There are satisfactory policies and procedures in place and records relating to medication are well maintained. Discussion with the manager and staff confirmed that further training has been provided from the local pharmacist who has also provided training packs to use with staff. The home has obtained a new cabinet, which provides more secure facilities for storing medications. Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Residents are protected by the procedures and systems in place for dealing with complaints and adult protection matters. EVIDENCE: There is a satisfactory complaints procedure in place, which is also provided in symbol form. A copy of the complaints procedure is contained on each resident’s individual file and demonstrated that this had been explained to residents. A resident’s comments indicated that he would feel comfortable to talk to staff and raise concern if he had a problem. Additionally tenants meetings are held where any concerns can be raised and records are kept of matters discussed in various forms such as audio as well as written. Neither the home nor the CSCI have received any complaints about the service in the past eighteen months. There is an adult protection procedure in place and staff spoken to were aware of what to do should any matter or complaint be raised. The home has referred a matter to social services under adult protection procedures since the Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 17 last inspection and has taken appropriate action to ensure residents welfare whilst it is being investigated. Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 27 The home provides a clean, tidy and comfortable environment for people who use the service, which is generally well maintained, however will benefit from the planned refurbishment of the bathrooms and toilets. EVIDENCE: Those areas of the home seen on the day included, the lounge, three residents rooms, the dining kitchen, staff office, bathrooms and toilets. All areas were clean and tidy. Bedrooms were individually arranged and furnished and Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 19 reflected residents particular interests and preferences. One was in the process of being redecorated and the acting manager confirmed that residents are consulted about their preferences prior to redecoration. Bedrooms are all for single occupancy and those seen offered residents spacious accommodation. Discussions and observations made indicated that residents are consulted about the décor of the home in relation to communal areas such as lounges. Quotes were seen to demonstrate that there is an ongoing programme of improvements to the home for example bathrooms and toilets are planned to be up-graded. Bathrooms have been provided with locks since the last inspection however these need some adjustment to ensure that they are easy to use. An environmental health officer last inspected the kitchen area on 01/02/06. Minor recommendations were made which the manager confirmed had received attention. Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 36 The home is staffed to ensure that residents’ needs are met. Staff are well trained and the recruitment procedure followed ensures as far as possible that residents are protected. EVIDENCE: Records checked and discussion with staff indicated that the home is being staffed to meet current residents needs. There is a consistent staff team (no new staff other than the acting manager have been employed since the last inspection). On the day of the visit there were two staff and the acting manager on duty at the start of the inspection. At night there is one staff member on duty who “sleeps in”. There is a system where an emergency oncall person can be called in if necessary. Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 21 Comments from a resident indicated that he felt able to talk to staff if he had a problem and a good rapport was observed between staff and residents. Records of the recruitment process demonstrated that there is a satisfactory procedure in place which includes criminal records bureau checks, proof of identity and the taking up of written references. Records are kept of the interview process. Discussions with staff and the checking of a staff members training records demonstrated that there is programme in place which ensure that staff have the necessary skills and knowledge to care for residents safely. For example there is an induction programme and regular updates on some matters such as manual handling and fire training as well as training which is more specific to meet the needs of residents. Staff indicated that they felt well supported and there is a supervision and development system. Team meetings are held regularly. Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. The home is well managed and there are effective systems in place for consultation with residents about the quality of the service. Risk assessments are in place to ensure residents health and welfare but need to be developed further in relation to hot surfaces to ensure residents safety. Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 23 EVIDENCE: There has been a change to the management arrangements of the home since the last inspection. An acting manager has been appointed who has submitted an application to the Commission to become registered. She has completed her National Vocational Qualification award level II and is working towards level III and has commenced the Registered Managers Award. There is a satisfactory quality assurance system in place. This includes seeking the views of residents and their relatives. Questionnaires are used and these are available in symbol form. The last service review occurred on 15/12/05. From this a development plan for the home was drawn up. There are also monthly visits from a representative of the organisation, monthly team meetings and residents meetings held to monitor residents satisfaction with the service. The organisation has a range of policies and procedures relating to health and safety issues in order to safe guard staff and residents. There is also a stafftraining programme in place, which ensures that health, and safety matters are covered such as manual handling and fire safety training. A staff member confirmed that training about infection control was planned to occur within the next week. The sample of records checked on this occasion demonstrated that health and safety matters such as fire safety are checked regularly. For example records were available to demonstrate that checks of the fire alarm system are conducted weekly, a fire risk assessment was in place which had been reviewed on 07/12/05 and there were records kept to indicate that the contents of the first aid kit were checked regularly. Health and safety risk assessments were in place in relation to some matters but it was noticed that these did not include risks posed to residents from hot surfaces such as radiators, which were unguarded. The acting manager agreed that this matter would be given attention. Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 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. Where there is no score against a standard it has not been looked at during this inspection. 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 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 X 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 3 40 X 41 X 42 2 43 X 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Whitwell Score 3 X 3 X DS0000002388.V285077.R01.S.doc Version 5.1 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA42OP38 Regulation 13(4) (a) & (c) Requirement Action must be taken to ensure risk assessments are undertaken and documented in relation to potential risks that hot surfaces pose to residents such as radiators. Action must be taken to ensure residents are adequately protected from any risks identified. Timescale for action 14/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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. Whitwell DS0000002388.V285077.R01.S.doc Version 5.1 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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