Inspection on 25/03/08 for Wisteria Lodge

This inspection was carried out on 25th March 2008.

CSCI found this care home to be providing an Excellent service.

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

Wisteria Lodge 06/03/07

Similar services:

Thorndene

Sutton Lodge Nursing Home

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Wisteria Lodge Horney Common Nutley Nr Uckfield East Sussex TN22 3EA Lead Inspector Debbie Sullivan Unannounced Inspection 25th March 2008 09:30 Wisteria Lodge DS0000067935.V359547.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 Wisteria Lodge DS0000067935.V359547.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. Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wisteria Lodge Address Horney Common Nutley Nr Uckfield East Sussex TN22 3EA 01825 714080 01825 714081 wisterialodge@sussexhealthcare.org www.sussexhealthcare.org Sussex Health Care 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) Mr Rezaul Hossen Care Home 10 Category(ies) of Learning disability (10), Physical disability (10) registration, with number of places Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is ten (10). Service users must be aged between eighteen (18) years and sixty-five (65) years on admission. Service users with a learning disability only to be accommodated Service users may also have a physical disability. Date of last inspection Brief Description of the Service: Wisteria Lodge is a care home registered for ten service users who are between eighteen and sixty-five years of age and who have a learning and physical disability. The home is registered to provide nursing care. The home is located off the main A22 road, it is owned by Sussex Healthcare who own numerous care homes throughout the South of England. Wisteria Lodge is located on the same site as another care home owned by Sussex Healthcare. These services are run independently from each other and both have their own communal facilities. The home is purpose built with wheelchair access throughout. All rooms are for single occupancy and ground floor. Staff accommodation is provided on the first floor. All rooms are provided with a toilet and shower en suite facilities. Overhead tracking hoists are located in some areas of the home. There is a good-sized lounge room, dining and activities area and a sensory room. An accessible garden area is located off the dining area. In addition to en suite facilities there is a wet room with shower and toilet facilities, an assisted bath and a large spa bath for service users to use. The weekly fee range for the service is currently £1,800 to £2,000. Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over five and a half hours. During the visit time was spent with service users, the registered manager, care and nursing staff and the homes’ physiotherapist. The registered manager came in from annual leave. A range of records and documentation were inspected including care plans, quality assurance information, staff records and policies and procedures. A tour of the property took place and service users were spoken with individually or together at lunchtime. Five service users were present during the visit and staff assisted them to communicate. Information was also gained from survey forms returned by relatives and service users. Service users had been assisted with the completion of their forms by relatives. Information was also provided in the AQAA (Annual Quality Assurance Assessment) document returned by the registered manager. The content of the AQAA was of good quality and clear, and it gave a good picture of how the home had assessed it’s improvements over the past year and plans for future development. The quality rating for this service is excellent. This means the people who use this service experience excellent quality outcomes. What the service does well: The home’s admission processes are thorough; attention is given to making sure that the needs of new service users are met as fully as possible with the opportunity for inclusion of relatives and other carers during the early stages of admission. Care plans clearly reflect the health and personal care needs of service users and are accessible to them. Needs are met as fully as possible and staff encourage service users to be independent. Care is provided as consistently as possible by staff who have in depth awareness of needs. Service users can take part in a well organised large range of activities at home and in the community; the activities coordinator has been creative in expanding the programme and looking for new experiences for service users. The home communicates well with relatives. Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 6 The environment is purpose built and designed to meet the needs of service users. Plenty of equipment for shared or personal use is provided. Complaints are effectively managed and service users have plenty of opportunities to offer views on the service. Staff are well trained and cheerful and are offered opportunities to progress. Staff relate well to service users and are genuinely interested in their lives. The home is well managed and organised and has a homely and friendly atmosphere. What has improved since the last inspection? What they could do better: Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 7 No requirements have been made as a result of this inspection. A recommendation has been made that care plans include evidence that service users are consulted as regards gender preference in respect of their personal care. 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. Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 4 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Needs are fully assessed prior to admission. Service users are provided with accessible information and are encouraged to spend time at the home so that they can make an informed choice about moving in. EVIDENCE: The home is fully occupied and there were no plans for any changes to the service user group, service users living there are all those who moved in when the home was first opened. Service users are provided with good information about the home before they move in, the service users guide is in pictorial as well as written format and the introduction process is thorough. A full needs assessment is undertaken before a place is offered and service users spend time at the home, including overnight stays if necessary. When a service user first moves in relatives or carers are also invited to stay as well so that the transition is as seamless as possible, staff can be sure that care needs are met in the way that the service Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 10 user has been used to and there is efficient handover of care. The manager said that this process had ensured that service users felt confident about moving in and relatives built up good relationships with staff. Comments on the moving in process on service user survey forms included “I came to see this place before I wanted to live here” and “I came to see the home with my Nan and social worker and liked it very much”. Following admission reviews take place after six weeks, then at three and six month intervals. When the service user is settled reviews are held annually. Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 11 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 and 10 People who use this service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. Care plans provide comprehensive information on each service user’s needs and preferences. Service users are offered opportunities to make decisions about their daily lives and the running of the home. EVIDENCE: Each service user has a care plan; care plans read during the visit were comprehensive easily accessible, and included pictorial information so that service users could be involved in their care planning. Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 12 Person Centred Planning has been introduced and each care plan is reviewed monthly. Information on communication, health and personal care needs, likes and dislikes, dreams and aspirations and activities is recorded. Reviews take place with care managers and families, the manager gave an example of a very recent review where a need to explore more resources for a service user with visual impairment was highlighted. Care plans include risk assessments and a personal health plan that is also pictorial. Each service user has complex and individual needs; relatives are involved where necessary in consultation over preferences and routines. Service users are supported in making choices and decisions on a day-to-day and longerterm basis. Staff are familiar with their methods of communication, likes and dislikes and demeanour this helps service users to feel secure and understood. During the visit one service user was getting a bit excited and distracted at lunchtime (due the presence of an inspector, a new staff member starting that day and a party in the afternoon) , staff knew how to calm and encourage them and explained what was happening. Regular service user meetings take place as well as monthly menu meetings, these give service users opportunities to offer their views and changes and improvements take place as a result, such as different activities and meals. Records are stored confidentially only those contributing them have access. Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 13 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): 11,12,13,14,15 and 16 People who use this service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are offered a wide range of opportunities to widen their experiences and develop skills at home and in the community. Contact with relatives and friends is promoted. Meals are healthy, varied and nutritious and planned with service user consultation. EVIDENCE: Wisteria Lodge offers a wide range of opportunities for service users to develop skills and take part in educational, social and community activities. Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 14 An activities coordinator is employed on weekdays and over the past year there has been an increase in activities and outings. There are now more opportunities for outings at weekends as a member of staff who drives is on duty, a service user stated on a survey form that outings used to be limited at weekends but the situation is improved. Information on daily and weekly activities is clearly displayed for service users on a pictureboard. Activities at home include art and craft, a news group, story telling, sensory sessions and in good weather outdoor games and walks. External professionals specialising in these areas provide monthly professional story telling, and weekly music sessions. Some service users attend Crawley College or a local day centre; two were at college during the inspection. A library club has been started involving a weekly library visit to borrow books and audiocassettes. Fitness is promoted and regular swimming, bowling trips take place at home there are exercise sessions, hydrotherapy and reflexology sessions. Other new activities are the “Events Club” when service users can attend an event such as a show, concert or sporting event once a month at a venue in surrounding areas. Visits to a local church each Sunday are available for those who wish to attend. Service users can choose to spend time with others or on their own within the constraints of group living and some arranged activities, and the home is run as flexibly as is possible to accommodate their choices. Birthdays and other special events are celebrated; there was a party for one service user’s birthday on the day of the inspection, the dining room was decorated with balloons and banners and a disco was planned for later. Each service user is offered an annual holiday, photos of last year’s holidays are on display. Contact with relatives is promoted, the home has upstairs accommodation available for relatives who may wish to stay and relatives are invited to social activities and parties. Discussion with the manager and staff showed that they involve relatives appropriately and there is good two way communication. A monthly newsletter started in January 2008 is sent to relatives to help keep them up to date with events and news about the home. Menus are varied and there is always choice of meal, service users contribute to meal planning and a photographic menu has been made so that choice can be as informed as possible. Meals are cooked at the larger service next door; only breakfast is prepared at the home. Service users were joined at lunchtime and enjoyed their meals; the meal was taken in a relaxed atmosphere with staff chatting to them. One service user is on a special diet and two are on PEG feeding. Service users who were able to eat without assistance were given lots of praise and encouragement by staff. Dining room tables and equipment are designed to maximise independence at mealtimes. Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 15 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 and 21 People who use this service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of service uses are well met and recorded and good health is actively promoted. Staff treat service users with dignity and respect and are interested in their lives. EVIDENCE: Health care needs are well recorded on care plans, are detailed in the Health Action Plan and kept up to date, service users have complex needs and as well as receiving day to care from the nursing and care staff receive input from a range of health and social care professionals and intensive support from the homes’ physiotherapist. An occupational therapist visits weekly. Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 16 Staff are very aware of each person’s needs and each service user has their own keyworker and named nurse. The overall attitude of staff towards service users was one of respecting their individuality and independence and of genuine interest in their lives. Personal care is given discreetly and during the visit staff were observed to treat service users with respect and dignity. Personal care preferences are recorded although there was no record that service users had been asked about gender preference, the manager said this would have taken place and would make sure it was recorded. Due to the availability of a hydro spa and physiotherapist at the home, service users have made very good progress and whilst the physiotherapist is going to be spending less time there now the home and service users are well established, they will still be there very regularly and other staff will carry on the programmes under their supervision. Contact is maintained with outside professionals such as dieticians, chiropodists and dentists so that service users receive regular health checks and treatment, a local GP visits twice a week as does an occupational therapist. Service users all use the same GP practice but are not all registered with the same GP there, so any individual concerns are dealt with, or referred on to their named GP. Medication is administered by nursing staff and stored properly. A recommendation was made at the last inspection that handwritten entries on medication recording charts be signed this is now taking place. The manager is in the process of obtaining clear and detailed information about preferences in the event of terminal illness or death and this will be included on care plans. Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users and their representatives can be sure that their views are listened to and acted upon. Service users are kept safe by the procedures followed by the home. EVIDENCE: The home has a complaints procedure that is available in a format that service users can access. Service users would need support to complain and relatives advocate on their behalf, the manager said that they had been offered advocacy as well but so far no one had felt the need to take this up. A survey form included the comments that “they act immediately on issues identified”. There had been three complaints recorded since the last key inspection all had been properly responded to by the manager and action taken to resolve the issues. Service users also have opportunities to raise issues at regular service user meetings No safeguarding alerts have been raised since the home was registered, the safety of service users is protected with the use of robust recruitment Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 18 procedures and staff are well trained in adult protection. An adult protection trainer from the organisation was giving a session to staff during the inspection and staff are familiar with safeguarding procedures. The home does not provide appointeeship for service users, they each have relatives undertaking this role and clear records of personal expenditure are maintained by the home and head office with monthly statements being sent to appointees. Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 19 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 and 30 People who use this service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users live in an environment that is designed to meet their needs, safe, homely and clean. The independence of service users is promoted and specialist equipment provided. EVIDENCE: Wisteria Lodge is a relatively new purpose built home located on the same site as another of the organisation’s services, as such it is very well designed and suited to meeting the needs of those with physical and learning disabilities and is extremely well equipped, this ensures that service users do not have any Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 20 accessibility problems and can be as independent as possible. All the service users are wheelchair users. There is a large airy activities and dining room, large comfortable lounge, hydrospa room, sensory room and kitchen. The sensory room had been redecorated and now has more equipment. Service users’ bedrooms are all personalised and attractive and each room is ensuite with overhead hoist tracking. Equipment designed to meet individual needs is provided, two service users are visually impaired so their rooms include plenty of lights and tactile signs. Bathrooms and the sensory room also have tracking so that manual handling is kept to a minimum. Each room leads onto an outside patio and path that surrounds the building, there are very attractive views of surrounding countryside and some service users have set up bird feeding tables and plants in their own outside space. One room had been renumbered as its original number was unlucky in the culture of the service user occupying it. The home is well decorated and shared areas as well as bedrooms have lots of photographs on the walls of activities and outings there are pictureboards showing which staff are on duty and which service users are in or out, these are helpful for service users, staff and visitors. During the visit service users were accessing the sensory room, spa and enjoying being together and with staff in the activities and dining area. The atmosphere was homely and the home was clean. All heating is underfloor, this helps contribute to the safety of the home. One service user stated on a survey form that during the day they could spend time in the sensory room or their own room and another that the home was lovely and fresh and clean. The kitchen is used by staff to prepare snacks and breakfast; main meals are prepared in the adjacent home. Service users can access the kitchen with staff and cooking sessions are held. The garden is a work in progress and there are plans for its development this year, the manager said it will include a vegetable patch for service users to grow their own produce and a sensory area. Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 21 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): 31,32,33,34,35 and 36 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A well-trained, well supervised and competent staff group supports service users. Recruitment processes are thorough and safeguard service users. EVIDENCE: The home has a staff team that consists of a deputy manager, qualified nurses, carers, a physiotherapist, an activities coordinator, cleaner, part time administrator and part time maintenance worker. The manager is in the process of employing a part time gardener. Since the home was opened no agency staff have been used. There is a registered nurse on duty on each daytime shift with four carers. On the day of the inspection the home was adequately staffed. The activities coordinator was on leave that day so care staff led activities competently and Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 22 had time to do so as three service users had not returned from staying with relatives for Easter and two were at college, the staffing levels allow for time to be spent with service users for talking and other activities as well as for direct caring tasks. One service user has one to one staffing due to their needs. Over 50 of the care staff have an NVQ in care at level 2 or above as is required. Some staff files were read, they included a cross section of care and nursing staff, the files showed that the necessary recruitment checks are undertaken, tracked and recorded including CRB and POVA checks. Supervision takes place and is well recorded and there are staff meetings held. New staff receive induction and spend time shadowing other staff, a new member of staff started on the day of the inspection, they were well qualified and confirmed that recruitment checks and processes had been through and handled efficiently by the organisation. Staff training is tracked; mandatory training is updated and nursing staff attend compulsory training in topics such as continence, diabetes, wound care and staff supervision. The manager supervises nurses and nursing staff supervise carers. Training is provided by in house and external trainers, adult protection training was given to a group of staff by an in house trainer during the visit. Staff spoken with felt well supported and the staff team interacted well together, this helped to provide a calm and homely atmosphere, and as one member of staff commented there was very little behaviour that could be challenging as service users are made to feel very settled and staff know their needs well. One member of staff said that the home treated service users with dignity and was “getting it right” Comments on survey forms from service users included “The staff are very nice to me and treat me well” and “everyone is friendly”. Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 23 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): 37,38,39,40,41,42 and 43 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed in the best interests of service users and staff. It has an open and inclusive atmosphere and the health safety and welfare of service users and staff are protected. The views of service users are sought and taken into account. EVIDENCE: Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 24 The home has friendly and welcoming atmosphere and staff present during the visit were cheerful and helpful in providing information. The registered manager is a qualified nurse and has recently completed the Registered Managers’ award; the deputy manager is also working towards this qualification. Staff spoken with felt well supported and the manager, who came in from annual leave, was seen to be very approachable to service users and staff. Service users are offered opportunities to give their views on the service via service user meetings, the complaints procedure and one service user a month is asked their views in a quality assurance questionnaire on a rotational basis. A senior member of Sussex Healthcare visits the home regularly as is required. Relatives are asked for their views and the manager is going to be seeking feedback from outside professionals as well. The home has a range of organisational policies and procedures in place as well as those specific to the service, these are available to staff and well ordered. Throughout the inspection staff were observed to be using safe working procedures, manual handling is kept to a minimum to help safeguard service users and staff due to the overhead tracking and quantity of specialist equipment available. All staff have fire safety training and some have additional fire warden training, fire drills regularly take place and fire and other equipment is serviced and tested. The home is properly insured and plans are in place for the improvement and further development of the service such as development of the garden that will include a sensory area, further staff training opportunities and the provision of more specialist equipment for service users. Records needed in respect of service users, staff and the service overall are very well maintained and service users have access to and are included in the upkeep of their care plans. Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 25 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 4 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 4 25 3 26 4 27 3 28 3 29 4 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 4 14 4 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 3 3 4 3 3 3 4 3 Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No requirements were made at 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA18 Good Practice Recommendations It is recommended that the gender preference of service users in respect of staff providing personal care be recorded. Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Wisteria Lodge DS0000067935.V359547.R01.S.doc Version 5.2 Page 28 - 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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