Care Home: Banyard Road, 40

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What the care home does well What has improved since the last inspection? What the care home could do better: We have not made any requirements or recommendations as a result of this inspection. CARE HOME ADULTS 18-65 Banyard Road, 40 Bermondsey London SE16 2YA Lead Inspector Ms Alison Pritchard Unannounced Inspection 5 November 2008 10:30 th Banyard Road, 40 DS0000007108.V365888.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 Banyard Road, 40 DS0000007108.V365888.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. Banyard Road, 40 DS0000007108.V365888.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Banyard Road, 40 Address Bermondsey London SE16 2YA 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) 0207 231 4774 0207 261 4148 40banyard.road@choicesupport.org.uk www.choicesupport.org.uk Choice Support Caroline Mary Heffernan Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Banyard Road, 40 DS0000007108.V365888.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - Code PC to service users of the following gender: Female whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 3 31st July 2007 Date of last inspection Brief Description of the Service: The home is registered to provide care for three people who have learning disabilities. The home is managed by a ‘not for profit’ organisation called Choice Support (Southwark) which manages a significant number of care homes for people with learning disabilities in the borough of Southwark and elsewhere. The home is in a cul-de-sac in Bermondsey, close to Southwark Park where parking is available during daylight hours. It is indistinguishable as a care home. Other local facilities include a shopping centre, market, pubs, cafés and churches. The home is close to public transport routes. The home provides a statement of purpose, detailing what the service offers and provides. It also lists what people can expect in terms of their rights, the service and terms and conditions. They provide a service brochure, which gives details of the accommodation, local area and staffing support provided. The residents make financial contribution towards the cost of their placements. The weekly contribution towards rent is £35.80, and towards food costs is £29.40. The placing authority pays for the remaining cost of placements. At the time of the inspection there were no vacancies. Banyard Road, 40 DS0000007108.V365888.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 3 star. This means the people who use this service experience excellent quality outcomes. This inspection was unannounced and carried out over one day in early November 2008. The inspection methods included discussion with people who live and work at the home, inspection of service users’ files and a range of other records. Care plans were checked and aspects of these residents’ care were examined by case tracking. We also looked around the building. Earlier in the year we sent surveys to people with an interest in the service. Seven were returned completed, they gave us the opinions of some service users, staff, relatives and professionals involved with the home. Some weeks earlier we visited the head office of Choice Support to look at staff recruitment records. Our findings are reported in this report. The CSCI has access to information gathered through notifications from the home. A document called an ‘Annual Quality Assurance Assessment’ (AQAA) was completed by the Assistant Manager of the home in advance of the inspection and returned to us. The document provides information about how the home is addressing the National Minimum Standards along with factual information about the operation of the home. All of this information has been taken into account in compiling this report. Staff and service users from the home facilitated the inspection visits; they were helpful and courteous throughout the process. What the service does well: We received very good feedback from a range of people. Service users’ feedback included the following comments: • ‘I like living here, I like cooking, I put meat in the oven.’ • ‘Clean house’. • ‘It’s very good.’ • One person, when asked if the staff treat her well, said that they always do and added ‘they’re nice.’ Relatives also praised the care given by the home: • One person said that her relative’s cultural needs are considered by the home and said ‘staff take her weekly to visit Caribbean restaurants which she enjoys.’ • ‘constantly informs relatives no matter how small issues may be – communicates well.’ • ‘I’m pleased that my [relative] is very happy.’ Banyard Road, 40 DS0000007108.V365888.R01.S.doc Version 5.2 Page 6 Staff members said that they are well supported and that training is updated annually. One member of staff said she felt she had benefited from the training she has had to help her meet the service users’ cultural needs. The staff feedback about the management style was that the Registered Manager is helpful, supportive and hard working. ‘Manager always makes time if you need support, and supervises regularly.’ ‘Our Manager has worked exceedingly hard.’ A health care professional commented that the staff are ‘patient’ and had ‘good morale’. 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. Banyard Road, 40 DS0000007108.V365888.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 Banyard Road, 40 DS0000007108.V365888.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): 1, 2, 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission policy and procedure ensures that a potential service user and the home have enough information to make an informed decision. EVIDENCE: The statement of purpose and the service user guide have been reviewed and updated since our last visit to the home. We were sent copies of the revised documents. They provide accurate information in an accessible format, using plain English and pictures. The admission policy of Choice Support ensures that introductory visits are made to the home and that assessments are used to ensure that the placement is suitable. There have been no admissions to the home since the last inspection. Banyard Road, 40 DS0000007108.V365888.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, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users benefit from a care planning system which takes into account all aspects of their needs, including those from their cultures and religions. Considerable efforts are made to include the service users in care planning. They have opportunities to be involved in the day to day life of the home. Risks are well managed, and service users are supported to take part in activities as part of a fulfilling lifestyle. Information is handled carefully with regard to confidentiality and privacy. EVIDENCE: All of the people who live at the home have a detailed care plan which describes the care and support that they need and how it should be provided. The two care plans that we looked at gave good information about the service users’ needs and wishes. In each case the plan gave useful information about the service users’ culture and religion and what impact this has on how to provide care. The care plans are written from the point of view of the service user and use pictures and plain English. The key workers meet with the service users Banyard Road, 40 DS0000007108.V365888.R01.S.doc Version 5.2 Page 10 regularly to look at the progress made towards meeting their goals. This shows that the home is committed to involving the service users as far as possible in the care planning process. The Registered Manager recognises that it can be challenging to involve the service users in care planning. We were informed in the AQAA that the staff team is to receive further input on communication and this may assist. The managing organisation has links with a service called ‘Surprise’, (previously known as Customer Watch), which is a forum through which people with learning disabilities can express their views on the services provided through Choice Support (Southwark). This ensures that the opinions of service users generally are included in the overall planning of the organisation. The people who live at the home also meet with each other and staff at regular meetings so that they can discuss issues of general concern. All of the service users have contact with an advocate who has known some of them for a long time. All of the service users’ files included assessments, which have been conducted to assess the suitability of service users’ involvement in risky activities. They had been reviewed in the last year and highlighted a date for future review. Personal information is stored with due regard for confidentiality. Choice Support is registered under the Data Protection Act and there is a confidentiality policy to ensure that staff handle personal information with care. Banyard Road, 40 DS0000007108.V365888.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): 12, 13, 14, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users follow a range of activities in the community. The staff team is keen to assist the service users to have more opportunities to follow culturally appropriate activities. Service users have benefited from the commitment the staff have shown to ensuring that service users maintain relationships with their families. The menu is planned with the service users and reflects their individual needs and choices. EVIDENCE: The service users take part in a range of activities in the local community. They include attending line-dancing sessions; going to the ‘Pop –In’ social club; art and pottery classes; eating in restaurants; ten pin bowling and visiting a sensory room. The home has made contact with an organisation, which can assist a service user to observe her religion and be included in cultural events. We saw in minutes of meetings that the staff team is working towards expanding the range of activities in which the service users are involved. Banyard Road, 40 DS0000007108.V365888.R01.S.doc Version 5.2 Page 12 At the time of our visit one of the service users was on holiday in Blackpool with two members of staff. This is her second visit there and we were told that the news from Blackpool was that she was enjoying her trip. Other residents have been on day trips away from the home, as this is more appropriate for their needs and wishes. The home is commended for the way it has assisted service users to keep contact with family members and other people important to them. They support the service users to make and receive visits. There are two communal rooms so this offers some degree of privacy for the visits to the home. The routines of the home are flexible and the rota is devised to ensure that there is enough support available to accompany service users to activities. This has been challenging in recent months as, there have been staff shortages, (see Staffing below). The staff were observed to treat service users with respect and warmth. Some of the team have worked with some service users for a long time, know them well and have relaxed relationships with them. Some adaptations have been made to the home to account for service users’ disabilities. The door bell is linked to the lighting system so overhead lights flash when the door bell is rung. This allows all of the service users to be alerted when someone is at the door. A passenger lift ensures that all of the service users have access to all parts of the home. The service users choose their menu for the week and shop for food stocks with the assistance of staff. the people who use the service assist with cooking meals, one person told us that she likes cooking chicken. Photographs of meals ensure that all of the service users are able to make choices. If a service user does not like the planned meal then an alternative is prepared. The staff have information about the cultural, religious and nutritional needs of the service users so that they can assist them to make appropriate choices. The menu records and food stocks showed that there is understanding of the need for fresh items, fruit and vegetables to be included regularly. Banyard Road, 40 DS0000007108.V365888.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. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff have good information to meet the care needs of the people who live at the home. The staff pay good attention to the emotional and physical care needs of the service users and this has been praised by professionals involved with the home. Medication is well managed. EVIDENCE: All of the people who live at the home have key workers who are responsible for the co-ordination of care planning, with the guidance of the Registered Manager. The care guidelines, which we saw on files give clear information about how staff should provide care and this will assist them to be consistent. All of the service users are women, as is the staff team. This helps to protect service users’ dignity, as they are able to receive care from people of the same gender at all times. In the AQAA the Service Manager expressed a wish for the staff team to reflect more closely the cultures of the residents. We met two people who live at the home during our visit. They were both well dressed with regard for their ages, their cultures and the weather. The home has made contact with a specialist team for people with learning disabilities and they have been provided with the correct aids and advice to meet the needs of the people who use the service. Banyard Road, 40 DS0000007108.V365888.R01.S.doc Version 5.2 Page 14 The home has held ‘best interest’ meetings in situations when decisions need to be made about medical treatment and the service user is judged, after a mental capacity assessment’ unable to give informed consent. Through this process decisions can be made about the best course of action to take. This demonstrates that the home acts to promote the welfare of the service users with regard to their health care needs. There is well-documented information about the contact that people who live at the home have with medical professionals, including the GP; dentist and learning disability specialists. We received feedback from a health care professional who commented that the home always seeks advice appropriately and acts upon it to manage and improve the health care needs of the people who live in the home. We looked at the way that medication is managed in the home and found that problems identified on the previous inspection in July 2007 had been addressed and significant improvements made. None of the people who live at the home look after or administer their own medication. The medication is stored securely and the staff member in charge of the shift holds the key to the cabinet. There were good records of administration of medications and of disposal. All of the medication administration records had a photograph of the service user to aid identification. In one instance the medication profile had many amendments on it making it rather unclear. This was pointed out to the Registered Manager who agreed to amend the document. In July 2008 the Primary Care Trust Pharmacy service visited the home and found that the medication system was ‘well managed’ and they had ‘no concern or action points’. Banyard Road, 40 DS0000007108.V365888.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints and safeguarding procedures contribute to the protection of the people who live at the home. EVIDENCE: Choice Support has a complaints procedure and it is included in the service user guide. Although complaints were made in the year prior to the completion of the AQAA none were upheld, and all were resolved within 28 days. There have been no safeguarding adults investigations about the home. The service users who returned our surveys could identify someone to whom they would complain, as could relatives of service users. we noted that the minutes of a service users’ meeting included talking to service users about the complaints procedure and encouraging its use when necessary. The Annual Report issued by Choice Support includes information that the organisation has conducted a thorough review of their policies, procedures and training to ensure that they are aimed at the protection of people who use their range of services. Choice Support introduced a new ‘safeguarding adults policy and procedure’ in March 2007. The judgement of the CSCI is that this is a thorough document, which is clearly written, and links all the aspects of safeguarding. The policy also introduces a new initiative of an internal protection committee. It is judged that this demonstrates that Choice Support is actively working to improve processes and practice. When recruitment records were inspected we found that they contribute to the protection of people who use Choice Support services as they are thorough and meet the legal requirements. Staff are given a handbook, which includes a Banyard Road, 40 DS0000007108.V365888.R01.S.doc Version 5.2 Page 16 summary of the adult protection policy and the whistle-blowing policy. All staff have received training in safeguarding issues. The arrangements for managing the finances of service users are safe and help to protect their interests. The procedures include checking the balance of cash held, receipts for each item of expenditure and weekly management checks. We sampled some of the records and found that all items are receipted and tallied with the records. Large items of expenditure have to be authorised by Care Managers, and records of these agreements are kept. Banyard Road, 40 DS0000007108.V365888.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at the home enjoy a homely, safe and comfortable environment which meets their specialist needs. EVIDENCE: The home is situated on two floors with a large communal sitting room and kitchen/diner area on the ground floor. A lift allows access to the first floor for people with mobility problems. These and the hallway are all decorated to a good standard and were pleasant and homely. There are patio doors leading from the dining area to a ramp leading down to an attractive garden with a paved area and raised flowerbeds. The garden is fully wheelchair accessible. Residents’ bedrooms are suitable for their needs, large and pleasantly furnished. One bedroom needs more personal items to be added and a lampshade There is a walk in shower on the ground floor and a bathroom on the first floor. The bathroom has been redecorated and this has significantly improved the appearance of the room. The building was clean and hygienic, laundry facilities are suitable for the needs of the home. Banyard Road, 40 DS0000007108.V365888.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, 34, 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There have been staff shortages recently but as the posts have been filled we anticipate that soon there will be enough staff to support the residents with their needs. They permanent staff have received training, which is relevant to their role, and this helps them provide good quality care. The recruitment procedures are safe and involve service users. EVIDENCE: At the time of the inspection the home had been experiencing some staff shortages as there were two vacant posts. However recruitment had been underway and people identified to fill these posts and begin work at the home in the near future. This will bring the staff team to six members of care staff in addition to the Registered Manager. On the day that we visited two members of staff were accompanying a service user on a holiday so this made it rather more difficult to fill the rota. Some of the staff team were working additional shifts to ensure adequate cover for the home and a member of the bank staff team worked in the morning of our visit. Inspectors visited the head office of Choice Support to examine recruitment files. We examined twelve recruitment files. Staff members from all levels were represented in the selection and they are employed at a variety of registered care homes run by Choice Support in Southwark and Lambeth. The files were Banyard Road, 40 DS0000007108.V365888.R01.S.doc Version 5.2 Page 19 in good order and all but one item specified by Regulation was present in the files. All of the files had the required checks and references, including Enhanced CRB checks, two references, full work histories and verification that they are physically and mentally fit for their work. We found that the majority of files did not contain a recent photograph of the employee. We discussed this with a member of the Human Resources team and he has agreed to ensure that this is amended. We were pleased to see that service users have been involved in the recruitment process and see this as an area of good practice. All but one of the care staff have achieved a NVQ at level 2 or above. There is an overall training and development plan for the home and it specifies the mandatory training staff must undertake and the frequency with which it is required. This includes health and safety issues (moving and handling; fire safety; first aid; health and safety and food hygiene) and safeguarding issues. In addition arrangements have been made for some staff to receive training in The Mental Capacity Act; risk assessment and skills teaching. Banyard Road, 40 DS0000007108.V365888.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, 38, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good management systems in place and they contribute to the provision of good quality care. The management of the organisation is informed by a range of quality assurance systems. Health and safety is well managed. EVIDENCE: Since our last inspection the Manager of the home has been registered under the Care Standards Act. She has achieved NVQ3 and is working towards NVQ4 and the Registered Managers Award. She has significant experience of working with people with learning disabilities. The feedback which staff gave about the Registered Manager ’s impact on the home was very good and included the following comments: ‘Manager always makes time if you need support, and supervises regularly.’ ‘Our Manager has worked exceedingly hard.’ There are a number of ways that Choice Support monitor the quality of the service provided at the home. Managers of other homes within Choice Support Banyard Road, 40 DS0000007108.V365888.R01.S.doc Version 5.2 Page 21 carry out monthly visits. Reports of the visits are available in the home. They showed that the visits include discussion with residents and staff and examination of records. Senior managers within the group conduct audits of the service based on standards set by an organisation called REACH. It is aimed at assessing service users’ experience of life in the home. Senior managers conducted an audit in June 2008 and the report was positive, those aspects, which needed attention, have since been addressed. This demonstrates that the monitoring exercises are taken seriously and as a focus for improvement. The Directors, Managers and Trustees of Choice Support meet regularly with representatives of service users who sit on a ‘service user forum’. They are involved with reviews of policies and procedures and two people with learning disabilities are part of the organisation’s Quality Assurance sub-committee. A national survey by Values into Action (VIA) had been commissioned by Choice Support to assess the opinions of service users. At a more local level the Registered Manager completes a quarterly report for the residents’ placing authority. These monitoring systems supplement the internal scrutiny and act as a further safeguard for residents. Health and safety is well managed. As mentioned above staff have received appropriate training in a range of relevant health and safety issues. The records of checks of health and safety systems showed that they are done regularly, for example the last fire drill was in late October 2008; the fire risk assessment was done in March 2008; fire alarms are tested weekly as are water temperatures. Banyard Road, 40 DS0000007108.V365888.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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 3 3 X X 3 X Banyard Road, 40 DS0000007108.V365888.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 Banyard Road, 40 DS0000007108.V365888.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Banyard Road, 40 DS0000007108.V365888.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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