Care Home: 1 Yew Tree Road

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What the care home does well The home is newly opened for business. There were only three residents occupying the home at the time of this inspection. It is evident that residents benefit from living in a small well kept home where there is evidence that care is provided by a cheerful, motivated and welltrained staff team. Staff work well together for the benefit of the residents and have a kind, caring and consistent approach.1 Yew Tree RoadDS0000073095.V375743.R01.S.docVersion 5.2The home is well managed by a qualified and competent person who is committed and caring. The manager is supportive to the staff and is an advocate for the residents some of whom have complex needs. Written records are well kept and provide staff with sufficient information to provide the appropriate level of care. All risks to the residents are fully assessed and guidelines are in place to reduce the risks identified. Residents are provided with good levels of support and supervision. The resident`s dignity and choice are respected in all aspects of life. Respect for resident`s privacy is very important and the only limits to the resident`s freedom are for their safety and protection. Residents are positively encouraged to develop independence and are supported to make decisions about all aspects of their lives. The home and gardens are well maintained and provide plenty of space for residents to enjoy in safety. What has improved since the last inspection? Not applicable. This is the first inspection since the home was registered. What the care home could do better: There were no requirements arising from this inspection. Key inspection report CARE HOME ADULTS 18-65 1 Yew Tree Road Slough Berkshire SL1 2AA Lead Inspector Julie Willis Key Unannounced Inspection 2nd June 2009 09:00 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1 Yew Tree Road Address Slough Berkshire SL1 2AA 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) 01753 888688 www.Reach-disabilitycare.co.uk REACH Limited Miss Suzie Marie Houlton Care Home 8 Category(ies) of Learning disability (0) registration, with number of places 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 8. Date of last inspection N/A Brief Description of the Service: Yew Tree Road is operated by REACH (Rehabilitation Education and Community Homes Limited) a small private company. Yew Tree Road is a detached house close to Slough town centre. It offers care and support to male and female residents aged between 18 and 65 with learning disabilities and associated physical disabilities. The cost of the service is £1621 per week. 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that people who use this service experience good quality outcomes. This unannounced inspection took place on Tuesday 2nd June at 9 am. The inspector was in the service for approximately four and a half hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager, and any information that CQC has received about the service since it opened for business. Prior to the visit an AQAA (Annual Quality Assurance Assessment) questionnaire was sent to the Manager, which provided the inspector with information about the service. The inspector toured the building, examined records and met all of the residents. The inspector also spent time talking informally to staff and observing how care was being delivered to the residents. From the evidence seen by the inspector and comments received, the inspector considers that this service has a good awareness and understanding of equality and diversity issues and would be able to provide positive outcomes for residents in the areas of race, ethnicity, age, gender, sexuality, disability and belief. The inspector gave feedback about her findings to the homes Manager at the end of inspection. There were no legal requirements made as a result of this inspection. The Commission has received no information concerning complaints since the home opened. What the service does well: The home is newly opened for business. There were only three residents occupying the home at the time of this inspection. It is evident that residents benefit from living in a small well kept home where there is evidence that care is provided by a cheerful, motivated and welltrained staff team. Staff work well together for the benefit of the residents and have a kind, caring and consistent approach. 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 6 The home is well managed by a qualified and competent person who is committed and caring. The manager is supportive to the staff and is an advocate for the residents some of whom have complex needs. Written records are well kept and provide staff with sufficient information to provide the appropriate level of care. All risks to the residents are fully assessed and guidelines are in place to reduce the risks identified. Residents are provided with good levels of support and supervision. The resident’s dignity and choice are respected in all aspects of life. Respect for resident’s privacy is very important and the only limits to the resident’s freedom are for their safety and protection. Residents are positively encouraged to develop independence and are supported to make decisions about all aspects of their lives. The home and gardens are well maintained and provide plenty of space for residents to enjoy in safety. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents are provided with sufficient information to enable them to decide if the home will be able to meet their needs. People are fully assessed prior to admission to ensure the home will be able to effectively meet the residents need. EVIDENCE: From examination of the Statement of Purpose and Service User Guide it is evident that prospective residents are provided with sufficient information to decide if the home is right for them. The Service User Guide has been provided in a user-friendly pictorial format. It contains a copy of the written contract, which sets out in detail what is included in the fee, the role and responsibility of the provider and the rights and obligations of the individual. The Statement of Purpose is specific to the home and clearly sets out the homes aims, objectives and philosophy. A relative confirmed that they had been given sufficient information about the home before the resident was admitted and had been offered the opportunity to visit the home informally and to talk to staff and other residents. They said 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 9 that they were “impressed with the home” and had found the staff “helpful, understanding and supportive”. It is clear that admissions are not made to the home until a full needs assessment has been undertaken by staff of the home. Examination of the preadmission documentation for the three latest admissions evidenced that the needs assessment is comprehensive and holistic. Information had been gathered from a variety of sources and covered all essential areas such as physical and mental health care needs, cultural and faith needs, method of communication, family and social contact, activities and leisure and training and education. All information recorded was clear and concise. Additionally, the home always insists on receiving a copy of any care management assessment at the point of referral. In each file seen it was clear that the decision to place individuals at the home had been decided by a multi-disciplinary team of professionals along with the resident and their families. From discussion with management it is clear that significant time is given to planning the person’s admission. Staff are conscious of the need to ensure that the new admission will gel with existing residents. The new resident’s transition to the home is a slow and gradual process and is carried out at the prospective residents own pace. In one case the admission process was carried out over a number of weeks. From observation of practice it was clear that the residents were relaxed and comfortable in their surroundings and an obvious rapport had been built between staff and residents. 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plans were sufficiently detailed to enable staff to effectively meet residents need and activities that could be hazardous were underpinned by effective risk assessment and risk management strategies. Residents are encouraged and supported to make decisions in relation to their everyday lives and their individual goals appeared realistic and achievable. EVIDENCE: From examination of care documentation for three residents and discussion with staff and management it is clear that the home positively encourages users to develop new skills and to become as independent as possible. 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 11 There was evidence that residents are encouraged to participate in the activities of daily living within the limits of their individual capabilities and adequate levels of support and supervision are provided whilst involving them in daily routines and activities that could pose a risk to their safety. Residents are supported to take risks as normal elements in their everyday lives. The risk assessments in the files covered many risk areas such as action in the event of fire, bathing & showering, use of when needed (PRN) medication, use of equipment and use of transport. All risks had been fully assessed and guidelines had been put in place to minimise any risk to residents and to staff. Person centred plans are in use at the home and it is clear that staff have tried to involve the residents in their production. Each resident is compiling their own photographic diary which documents their daily activities and everyday lives. The residents are in the main non-verbal and the plans have been based on the staffs knowledge of the residents likes and dislikes and observation of their non-verbal responses, behaviours and gestures. Several of the residents use Makaton and can sign their needs. The care plans are entirely person-centred and recognise the individual and diverse needs of the residents. They included information about resident’s personal and health care needs, social activities, specialist needs and behaviour management guidelines. It was evident from observation of practice that they are working tools and in daily use. Staff were observed to respond to residents challenging behaviours in a planned and consistent way to avoid any escalation. From discussion with management it is clear that this team approach has reduced the severity of the challenges and has had a positive effect on the lives of the other residents. 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents take part in activities that provide opportunity for personal, practical and emotional development. Residents are encouraged to be part of the local community and citizenship is encouraged and supported. Residents are provided with a menu that is nourishing, varied and meets their individual and cultural need. EVIDENCE: The residents are provided with the opportunity to engage in activities that are stimulating and worthwhile. The daily records for the resident’s evidence that 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 13 residents make good use of communal facilities including local restaurants, cinemas, sports facilities and public houses. Residents are being supported to participate in a range of community-based activities including attendance at Thames Valley Adventure Playground, salsa classes at West Wing, swimming, use of the local library and attendance at the local ‘Mencap club’ held at Langley College. Community use is promoted and transportation to activities is either by the house vehicle, walking, taxis or local public transport. Examination of the staff rosters evidence that the staffing levels are sufficiently flexible to provide residents with adequate levels of staffing during activities. All residents will have the opportunity to participate in an annual holiday. A relative confirmed that one resident had visited Hastings and will be going to Pagham later in the year. Residents are encouraged to maintain their relationships with family and friends. Records indicate that two residents keep in regular contact with their family and have regular visits and correspondence. The third resident has no family contact but has a close friend who visits regularly. The resident has been referred to professional advocacy services for further support and guidance. The home provides a nourishing menu, which meets the needs of residents. Residents are provided with choice and variety and are regularly consulted about the menus during the monthly residents meetings. Coloured photographs of different foods are used to aid the residents understanding and to assist them in making a choice. 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents physical and personal support needs are well met and residents are provided with access to appropriate healthcare services. The systems for the administration of medication are good with clear and comprehensive arrangements in place to ensure residents safety. EVIDENCE: Examination of care documentation and discussion with staff and management indicated that all residents are registered with a local doctor. A number of the residents are regular attendees at hospital where they see consultants in psychiatry, psychology, epilepsy and nutrition. Details of the outcome of these appointments and any changes in treatment or medication are well documented in the care plans and daily records. 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 15 All residents have regular health checks and routine screening and treatments including dentistry, podiatry and attention to their vision and hearing. All residents are offered regular vaccinations against flu and other illnesses by their doctor and their decision as to whether or not to have treatment is documented in their care records. Each resident has a ‘Health Passport’ which keeps a record of their individual health and goes with them to appointments. Only staff trained in the safe administration of medicines may administer medication to the residents. Two staff do the medications together in order to provide a double check system with dual signatures on the MAR sheets and handover book. The administration, storage, recording and disposal of medication in this home ensure the safety of residents. From examination of three care records it is evident that resident’s physical and personal care needs are well met by the home. All care given is documented in the daily diaries and was observed to fully validate the content of care plans. Observation of staff and resident interaction demonstrated that care was provided in a manner, which maintained the users right to dignity, privacy, independence and choice. 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a satisfactory complaints system with evidence that residents views are listened to and acted upon Residents are protected from abuse and exploitation by the homes policies and procedures. EVIDENCE: There have been no complaints reported to the home since it opened. No information about complaints about the service has been forwarded to the CQC. Residents have access to the complaint procedure, which is explicit in the Service User Guide and is in a user-friendly pictorial format to aid residents understanding. Discussion with the Manager indicated that feedback is actively sought from residents and their families on a regular basis. The information provided, is used to enable the home to provide a personally tailored service to meet the needs of each individual resident. 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 17 The management deals with any issues that are raised by residents or their relatives swiftly and efficiently and is proactive in remedying any deficits in the quality of the service. All staff have received training in safeguarding adults as part of their induction to the home and additionally when gaining National Vocational Qualifications in which it forms a core module. The home has a copy of the Berkshire Interagency procedure on safeguarding adults of which all staff are aware. 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a clean, safe and comfortable environment. EVIDENCE: The home provides a physical environment that is appropriate to the specific needs of the residents who live there. The home has been newly refurbished and is clean, hygienic and well-maintained throughout. All communal areas are bright and cheerfully decorated. The gardens are large, safe, well kept and well used by the residents. Residents have been encouraged to grow their own plants and salad vegetables which they have clearly enjoyed. 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 19 The bedrooms have been personalised to reflect the preferences of the residents. All the homes fixtures and fittings meet the needs of individuals and can be adapted to meet residents changing needs. The management have an effective infection control policy; they seek advice from appropriate specialists and encourage the staff to work to the homes health and safety policy. 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are provided with care and support by a team of well-trained and caring staff that have been robustly recruited. EVIDENCE: Examination of the staff recruitment and training files for three workers evidenced that staff were appropriately recruited, inducted and trained. Selection and recruitment procedures at this home are robust. Records evidence that all necessary checks are carried out on staff to ensure that they possess the necessary attributes to care effectively for the residents. Records were well kept and met the required standard. From discussion with staff and examination of three training records it was clear that all staff have received structured induction and foundation training to Skills for Care specification. All new staff have attended core skills training in fire safety awareness, health & safety, infection control, safeguarding adults, food hygiene, first aid and manual handling. Following foundation training, 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 21 which is completed in the first six months, all staff are encouraged to attain National Vocational Qualifications at levels 2 & 3. Additional training is offered to the staff of the home to enable them to effectively meet the needs of residents with a variety of complex needs. This training includes understanding autism, PEG feed training, epilepsy, Makaton, non-violent crisis intervention and diversity, equal opportunities and cultural awareness. At the time of inspection staff were able to demonstrate caring and committed attitudes to the residents. Residents appeared relaxed and happy in the staffs care. The staff were clearly able to interpret resident’s non-verbal signals effectively and to offer residents appropriate choices in relation to their everyday lives. 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from living in a well managed home where management are qualified and competent and can demonstrate effective leadership skills. Residents live in a safe environment where risks to their safety are assessed, minimised, monitored and managed effectively. EVIDENCE: The home is well run by a Registered Manager who is competent and experienced to run the home and meet its stated aims and objectives. The Manager has achieved an NVQ level 4 in management and care. 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 23 Staff confirm that the Homes Manager demonstrates effective leadership skills and vision and is always keen to support individual members of staffs personal and professional development. Staff confirm that they have the opportunity to express their opinions openly in staff meetings, supervision sessions and staff handovers. They say that they are provided with plenty of opportunity to express concerns, share information and to feel included and involved in the way the service is delivered. The manager of the home operates an ‘open door’ policy and actively encourages suggestions, comments and recommendations from residents, staff and relatives. Quality assurance feedback is constantly gleaned from residents and relatives and from the staff team. The information is used to identify any gaps in service and to confirm that the home is effectively meeting its stated aims and objectives. Examination of the Regulation 26 (proprietor’s representative) reports indicate that Senior Management are regular visitors to the home. They carry out a mini-inspection at each visit, to check the home is meeting quality standards. There are plans by senior management to carry out regular quality monitoring surveys of all stakeholders once the home is fully occupied. A sample of health and safety records were examined including fire records, hot water temperature records and COSHH sheets. These checks evidenced that essential servicing and maintenance of equipment is undertaken routinely to safeguard the health and welfare of residents. Servicing and safety certificates were available on file. Examination of records indicated that all staff have received health & safety training as part of the induction and there are plans in place to ensure that all staff receive refresher training at regular intervals thereafter. Unnecessary risks to residents are identified using comprehensive risk assessments that are reviewed at regular intervals. So far as possible risks are reduced or eliminated. 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 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 x LIFESTYLES Standard No Score 11 3 12 3 13 x 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 x x 3 x Version 5.2 Page 25 1 Yew Tree Road DS0000073095.V375743.R01.S.doc N/A 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 Page 26 Care Quality Commission South East The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 1 Yew Tree Road DS0000073095.V375743.R01.S.doc Version 5.2 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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