Care Home: 128 Beech Hill

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What the care home does well The home has good strategies in place to enable residents to develop new skills and work towards achieving independence. Each resident has a comprehensive care plan in place that provides staff with detailed guidance about how they should provide support. Residents are supported by a skilled and committed team of staff who communicate effectively with each other by daily handovers and regular staff meetings to ensure that care is delivered in the most effective and consistent way.Residents are supported to be fully involved in the running of the home and their rights and responsibilities as adults living together are fully respected. Residents have access to opportunities that develop their educational, vocational and social needs. Activities are planned and facilitated across a twenty-four hour period, seven days each week. One resident has been supported to find part-time employment and on both inspection days, residents were busy participating in their planned activities. The home is an attractive and spacious property with a location that facilitates independence. The residents have been fully involved in the decoration and furnishing of the home. Each resident has their own key to their bedroom. What has improved since the last inspection? The organisation has developed its systems for monitoring quality assurance and monthly spot checks on the service are now being conducted to ensure the home continues to run effectively. The Disabilities Trust has now been accredited as a National Vocational (NVQ) centre and with an increased number of NVQ assessors, the number of staff undertaking NVQ training has started to increase. What the care home could do better: The feedback received from stakeholders should be collated and published to demonstrate how the service responds to the views of interested parties in respect of shaping the future of the service. Health action plans for residents that are in line with Valuing People recommendations should be in place. The above areas have not been reflected as requirements or recommendations as the home has robust systems in place to self monitor and improve. The CSCI is therefore confident that the internal mechanisms in place are sufficiently robust to identify and implement its own areas for improvement. CARE HOME ADULTS 18-65 128 Beech Hill 128 Beech Hill Haywards Heath West Sussex RH16 3TT Lead Inspector Lucy Green Key Unannounced Inspection 9 & 14th January 2008 09:50 th 128 Beech Hill DS0000062353.V356304.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 128 Beech Hill DS0000062353.V356304.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. 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 128 Beech Hill Address 128 Beech Hill Haywards Heath West Sussex RH16 3TT 01444 239123 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) The Disabilities Trust Mrs Susan Caroline Stopa Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Commission for Social Care Inspection has agreed that Mrs Susan Caroline Stopa can be the registered manager of this service as well as Hollyrood because it is a `satellite` of the home. 14th December 2006 Date of last inspection Brief Description of the Service: 128 Beech Hill is registered to provide personal care for up to four people with learning disabilities. The home is a two-storey detached property situated in a quiet residential area of Hayward Heath. Resident accommodation consists of four single bedrooms. Communal areas comprise of a large lounge, dining area, games room, kitchen, two bathrooms and separate toilet. A garden is situated rear of the home and limited parking is available at the front. 128 Beech Hill is a satellite home connected to Hollyrood care home, which offers a service specifically to meet the needs of people within the autistic spectrum. 128 Beech Hill accommodates four people who are able to live a more independent life but need the support of a care home rather than supported living. More detailed information about the services provided at 128 Beech Hill, including the range of fees can be found in the home’s Statement of Purpose and Service User Guide - copies of these documents can be obtained directly from the Provider. Latest CSCI inspection reports are on available on request from the home. 128 Beech Hill DS0000062353.V356304.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 star. This means the people who use this service experience good quality outcomes. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at 128 Beech Hill are referred to as ‘residents’. This report reflects a key inspection based on the collation of information received since the last inspection, a review of the home’s Annual Quality Assurance Assessment (AQAA) and a site visit, which lasted for a total of three hours and twenty minutes. The inspection was conducted across two days, with the first visit being unannounced. When the Inspector arrived on the first day, the routines of the residents meant that everyone was scheduled to be out of the home by 12:30pm. It was therefore arranged for the Inspector to return five days later to meet with the Team Leader and conduct the rest of the inspection. The site visit included a partial tour of the premises and an examination of some medication, care and staffing records. Throughout the inspection process, the Inspector met with all four of the people living in the home and was able to speak individually with one of them. Due to the needs of the people living at the home, the Inspector’s interaction with the residents was required to be informal and based on distant observation. The Inspector spoke with the Team Leader, the Managing Team Leader, and interviewed the Senior Carer and a Bank Support Worker in private. What the service does well: The home has good strategies in place to enable residents to develop new skills and work towards achieving independence. Each resident has a comprehensive care plan in place that provides staff with detailed guidance about how they should provide support. Residents are supported by a skilled and committed team of staff who communicate effectively with each other by daily handovers and regular staff meetings to ensure that care is delivered in the most effective and consistent way. 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 6 Residents are supported to be fully involved in the running of the home and their rights and responsibilities as adults living together are fully respected. Residents have access to opportunities that develop their educational, vocational and social needs. Activities are planned and facilitated across a twenty-four hour period, seven days each week. One resident has been supported to find part-time employment and on both inspection days, residents were busy participating in their planned activities. The home is an attractive and spacious property with a location that facilitates independence. The residents have been fully involved in the decoration and furnishing of the home. Each resident has their own key to their bedroom. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 128 Beech Hill DS0000062353.V356304.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 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use 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 benefit from an admission process that ensures their individual needs and aspirations are appropriately assessed prior to moving into the home. Current residents enjoy living with a group of people they know and who they are compatible with. EVIDENCE: The home has not had any admissions since the last inspection and therefore Standard 2 was not re-inspected on this occasion. The residents at 128 Beech Hill have lived together for a number of years, both at Hollyrood and now at 128 Beech Hill. The management team reported that should a vacancy occur, the home would use the same admissions procedure that has previously been assessed as good. The Annual Quality Assurance Assessment (AQAA) that was completed by the Registered Manager provided evidence of a detailed admission policy that includes giving prospective residents the opportunity to visit the home. The AQAA emphasises that compatibility with existing residents is key in the assessment of any new resident. 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 9 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 & 9 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The high standard of care planning provides staff with an excellent foundation to support residents in a way that both enables and protects them. Residents are fully consulted and involved in all decisions about their lives. EVIDENCE: Through discussion with staff and observation of their practices, it was demonstrated that they have good relationships with the people they support and an excellent understanding of their needs. A review of the care plans in place for two residents revealed that staff understanding and practices are a reflection of the high standard of care planning at 128 Beech Hill. Both care plans comprehensively outline the care needs of the individual in a way that is accessible and person centred. The two 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 10 staff members spoken with confirmed that care plans are integral to the way they work. It was evident during the inspection that care plans are working documents that are referred to and utilised every day. The management team informed the Inspector that the service was in the process of making further improvements to the care planning system and a copy of newly written risk assessments demonstrated that such improvements are going to further enhance a system that is already working well. Goal setting and monitoring are fundamental principles in the way care plans are constructed. Both care plans viewed contain individual goals for each resident to enable them to achieve maximum independence and develop their skills. Each goal is backed up by detailed guidelines which explain how staff should support residents in order to achieve that goal. Goals are monitored through the use of recording sheets and discussed regularly with the resident and reviewed formally at least every six months. Staff spoken with demonstrated that they are aware of the goals in place and how they should provide support to assist each resident achieve their goals. A full care review is held at least once every six months. Minutes from these meetings were viewed and found to be detailed and focused and adopt a multidisciplinary approach. A range of detailed risk assessments are in place for both of the residents’ whose care was tracked. The home has a positive approach to risk taking and residents are supported to take risks to maximise choice and independence. Through careful risk assessment and support plans, it is evident that the home enables residents to make real achievements. Risk assessments are linked to goals and skill teaching, for one resident this includes detailing the steps in place for staff to assess the individual’s road safety awareness, so that eventually they will be able to access the community independently. Evidence gathered from documentation and observation of staff supporting residents during the inspection, highlights that the home provides a service where residents are encouraged and supported to lead independent lives. It is noted that where rights have to be limited for the well-being of residents these are fully agreed with resident. 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 11 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, 15, 16 & 17 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are appropriately supported to lead independent lives and to develop their educational, vocational and social skills. Residents have the opportunity to plan and prepare their own balanced and nutritious meals. EVIDENCE: On arrival at the home, it was immediately evident that the residents at 128 Beech Hill lead active and fulfilling lives. Two residents had gone out bowling with two staff members, one resident was just leaving to go to work at a local nursing home and the fourth resident was at home working through his inhouse programme of activities. The weekly planner in the lounge provides evidence that each resident has an activity timetable that enables them to participate in a range of appropriate 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 12 and fulfilling activities. The philosophy of this service, as reflected in the AQAA and in the practices observed, is to develop individuals’ life skills and support residents to achieve maximum independence. Residents are fully involved in the running of the home and consequently time is built into their schedules to undertake household tasks. The home is actively supporting one resident to move onto more independent living in the near future and as such their activity programme incorporates time for skill teaching, which includes supporting this individual to learn how to plan, shop and cook meals. The information provided by the weekly timetable, care plans, discussions with residents and staff revealed that residents continue to access a range of educational, vocational and social activities. The planning of activities is arranged across morning, afternoon and evening periods, seven days per week. Residents are fully integrated with their local community and make use of available facilities, including; colleges, pubs, cinema, shops and leisure clubs. Discussion with staff identified that staff respond appropriately and flexibly to residents’ needs and choices. As such, whilst there is a structured timetable of activities in place, staff are able to respond sensitively if residents request ‘space’ or ‘time out’. It was observed that residents have keys to their bedroom doors and staff respect their private space. For this reason it was not possible for the Inspector to undertake a full tour of the home, as bedroom doors were locked when residents are out. Documentation and evidence reflects that residents have the freedom to live their lives as they choose, whilst understanding the need to be respectful to the other people they live with and to maintain their safety via a risk assessed framework. The home has a positive approach to enabling residents to maintain and develop contact and relationships with families and friends. There is evidence in the care plans that the home supports residents to meet with and receive visits from their relatives. Resident reviews include the opportunity for residents’ relatives/representatives to attend if the resident wishes. Meals at 128 Beech Hill are prepared according to a weekly menu. The menu is drawn up in consultation with residents to reflect the meals they wish to have. The menu is also reflective of individual likes and dislikes and therefore some days different meals are prepared for different residents. Residents also have responsibility for the purchasing of ingredients, preparation and cooking of their own meals. The menus seen include a range of varied and wellbalanced meals. 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 13 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 People who use 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 the provision of flexible and respectful personal and healthcare support and are protected by the systems in place to manage medication. EVIDENCE: Residents at 128 Beech Hill largely manage their own personal care. Staff support is provided by the offering of verbal prompts at identified key times. Risk assessments are in place to ensure the safety of residents at all times. The philosophy of the home is to support residents to achieve maximum independence and systems are in place to assist residents to take full responsibility for their own personal care. Care plans provide detailed guidance for staff as to how they should support each individual. Staff meetings and daily handovers provide the opportunity for staff to discuss the way support is provided and ensure that care is delivered consistently by all parties. 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 14 Staff support residents to ensure their health needs are met. Care plans contain a record of any visits or contact with healthcare professionals, along with the monthly monitoring of residents’ weights. The home has not currently introduced health action plans in line with ‘Valuing People’. The Managing Team Leader stated that the new system of care planning incorporates health action plans and will these will therefore be in place very shortly. For this reason, this is not reflected as a requirement. A review of the storage and recording of medication and discussion with the Senior Support Worker identified that systems are in place to ensure medication is managed appropriately. Medication is always witnessed and signed by a second member of staff. Staff receive in-house training in the management of medication and are assessed as competent by either the Team Leader of Senior Support Worker following a period of shadowing. 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use 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 the systems in place to listen to their views and safeguard them from harm. EVIDENCE: The home has a complaints procedure in place and an accessible copy is kept in the lounge for residents’ and visitors to access. Neither the CSCI nor the home however have received any complaints about the service at 128 Beech Hill since the last inspection. The home seeks to operate an open culture where issues are openly discussed and opinions shared. Positive interaction was observed between residents and staff during the inspection. Residents are encouraged to voice their opinions about the things they like and dislike. The home has a number of systems in place to protect residents from abuse. New staff are employed subject to robust recruitment procedures and the necessary checks being undertaken. There are appropriate systems for supporting residents’ with their finances. The two staff spoken had received training in the protection of vulnerable adults and demonstrated that they are aware of their responsibilities in respect of protecting vulnerable adults. 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 16 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 & 30 People who use 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 a homely, safe and comfortable environment that meets their needs. EVIDENCE: The Inspector undertook a partial tour of the home, which included the communal areas and one bedroom. Residents lock their bedrooms when they are out and therefore it was not possible to view all of these. The home is decorated and furnished to a high standard. The home comprises of four single bedrooms and an office. The kitchen, lounge, games room and dining room provide residents with sufficient communal space to meet their needs. Residents also have access to a garden at the rear of the property. 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 17 Residents are supported to take responsibility with staff for keeping the home clean and tidy and this was found to be the case at the time of the inspection. Staff spoken with confirmed that there are no outstanding maintenance issues that are not being addressed and the home also has rolling maintenance programme in place. 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 People who use 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 a dedicated and competent team of staff and are protected by the robust recruitment procedures. Staff have both the skills and support to enable them to perform their roles effectively. EVIDENCE: At the time of the inspection, the atmosphere was observed to be friendly and relaxed and the positive relationships between staff and residents were obvious. On the first day of the inspection, the home was staffed by three support workers. Two staff and the management team confirmed that the home is always staffed with a minimum of three staff during the day, with four staff at designated times. At night, one staff member sleeps-in. The rotas viewed reflected these figures as accurate. 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 19 Discussion with two staff and examination of two staff files identified that training is ongoing. There is documentary evidence that new staff members complete an induction programme in line with Skills for Care. Staff files also provide evidence of a robust system of recruitment being in place – with all the correct documentation and checks being in situ. Staff have access to a raft of mandatory and specialist training including; fire safety, first aid and adult protection, epilepsy, manual handling and behavioural support. The organisation also provides staff with Autism and Asperger’s specific training. The staff who met with the Inspector demonstrated a good understanding of the needs of the people they support and confirmed that they felt competent to carry out their roles effectively. It was a requirement of the last inspection that the home ensure a minimum of 50 of care staff are trained to at least National Vocational Qualification (NVQ) level 2 in Care. Whilst this target has not yet been achieved, the home is working towards improving the number of NVQ trained staff. The AQAA also highlights that the organisation has now been approved as a centre for NVQ and as more assessors are trained, the number of candidates undertaking NVQ’s can increase. As the home has evidenced its own systems in place to improve this area a requirement has not been made. The Inspector saw evidence of regular staff meetings being conducted with minutes recorded. There is a supervision system in place that provides staff with formal 1-1 sessions every six weeks. 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People who use 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 the home being run by an experienced and committed management team who ensure that the home is run safely. The organisation has systems in place to self-audit and monitor. EVIDENCE: The Registered Manager is based at Hollyrood, which was agreed with the CSCI as 128 Beech Hill is a ‘satellite’ of this service. The Registered Manager holds an NVQ in both care and management. The daily running of the home is managed by a Team Leader who works ‘hands on’ with one day each week dedicated to administrative tasks. A Managing Team Leader provides the link between the Team Leader and the Registered Manager. These management 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 21 arrangements are working well with the effect of a home that is running efficiently and effectively. The home has a system of quality monitoring in place with the Managing Team Leader conducting regular visits in accordance with Regulation 26 and reports for the most recent of these visits were viewed. The AQAA confirms that annual satisfaction surveys are sent out to families and staff, although at the current time the results of these have not been formally collated and published. It was discussed with the management team that this should be carried out and other relevant stakeholders included in the process. The home is accredited by the National Autistic Society and has achieved this accreditation for the fifth year in a row. The AQAA provides evidence that the home has various systems in place to ensure the Health and Safety of the home are maintained. The Inspector did not have cause to question the way health and safety is maintained and therefore records in respect of health and safety were not inspected on this occasion. 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 3 12 4 13 4 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 X 3 X X 3 X 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 128 Beech Hill DS0000062353.V356304.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection 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. 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