Care Home: Bevern View

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What the care home does well Bevern View provides a specialist service to younger adults with profound and complex needs. Both the management team and staff have the necessary skills and experience to deliver this service well. The home has excellent strategies in place to enable residents to maintain and develop their skills. Each resident has a comprehensive care plan in place that provides staff with detailed guidance about how they should offer support and outlines a system for the setting and monitoring of goals. 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 and are entirely tailored to the needs and interests of the individual. On the day of the inspection, residents were busy participating in their planned activities, which included sailing,cooking and massage and music sessions. Throughout the inspection staff were observed engaging fully and appropriately with the people they support. Bevern View has a robust system of quality monitoring and through comprehensively completed audits the service has demonstrated a genuine commitment to improvement and service progression. What has improved since the last inspection? The last few inspections have demonstrated ongoing improvements within this service and the period between the last inspection in July 2006 and this visit is no exception. The two requirements made at the previous inspection have been fully complied with and in addition the home has generated its own action plans for development. The home has been working hard developing the care planning system to ensure that it is fully person centred and integrated with activities to provide a holistic package of support. Health action plans have been introduced for each individual and highlight effective multidisciplinary working. Discussion with the Responsible Individual identified that the service is currently looking at major environmental development to provide residents with a future service that fully meets their individual and collective needs. CARE HOME ADULTS 18-65 Bevern View The Willows Deans Meadow Barcombe Lewes East Sussex BN8 5DX Lead Inspector Lucy Green Key Unannounced Inspection 10th July 2008 10:50 DS0000013963.V367005.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 DS0000013963.V367005.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. DS0000013963.V367005.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bevern View Address 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 Willows Deans Meadow Barcombe Lewes East Sussex BN8 5DX 01273-400752 01273 400568 administrator@bevernview.org The Bevern Trust Mrs Rosemary Anne Milmine Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places DS0000013963.V367005.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is eight (8). Service users must be aged between sixteen (16) and forty (40) years of age on admission. Service users with a learning disability to be accommodated. Service users with additional physical disabilities may also be accommodated. 13th July 2006 Date of last inspection Brief Description of the Service: Bevern View is a purpose built care home that provides support and care for a maximum of eight people with profound disabilities and complex needs between the ages of 16 to 40 years of age. One place is provided for respite care. The home is situated in the village of Barcombe and aims to provide a service to people from within a 15 mile radius. The home seeks to involve residents in the local community wherever possible. Families and freiends are encouraged to visit and to be actively involved in the decision making processes and care plans of the individuals resident in the home. Referrals to the home are often made by parents who also seek funding from the social services department. Costs of placements vary according to the package of care needed to support the individual. More detailed information about the services provided at Bevern View, including the current range of fees can be found in the home’s Statement of Purpose and Service User Guide - copies of these documents, along with the latest CSCI inspection reports are on available at the home. DS0000013963.V367005.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. 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 Bevern View 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 and an unannounced site visit which lasted six hours on Thursday 10th July 2008 between the hours of 10am and 2:40pm. The site visit included a partial tour of the premises and an examination of some care, medication and staffing records. The Inspector observed the interaction between staff and residents as they undertook activities and prepared and served the lunchtime meal. Throughout the inspection process, the Inspector met with seven of the eight people living at the home and observed the daily support provided to five of them. Time was also spent individually with the Registered Manager, Deputy Manager and three support workers on duty were interviewed in private. The Inspector also had the opportunity to speak with a relative and the Responsible Individual who both visited during the course of the inspection. What the service does well: Bevern View provides a specialist service to younger adults with profound and complex needs. Both the management team and staff have the necessary skills and experience to deliver this service well. The home has excellent strategies in place to enable residents to maintain and develop their skills. Each resident has a comprehensive care plan in place that provides staff with detailed guidance about how they should offer support and outlines a system for the setting and monitoring of goals. 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 and are entirely tailored to the needs and interests of the individual. On the day of the inspection, residents were busy participating in their planned activities, which included sailing, DS0000013963.V367005.R01.S.doc Version 5.2 Page 6 cooking and massage and music sessions. Throughout the inspection staff were observed engaging fully and appropriately with the people they support. Bevern View has a robust system of quality monitoring and through comprehensively completed audits the service has demonstrated a genuine commitment to improvement and service progression. 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. DS0000013963.V367005.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 DS0000013963.V367005.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 Quality in this outcome area is good. This judgement has been made using available 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: One new resident has moved into the home since the last inspection. This individual used to stay at Bevern View on a respite basis prior to accepting a permanent placement. The Registered Manager therefore confirmed that the initial assessment for this person was obtained before respite commenced, after which a care plan was put in place. As none of the individuals currently receiving services from Bevern View have been assessed since the last inspection, the Inspector decided not to view assessment information. The last inspection report identified that preadmission assessments were very detailed and contained the required level of information. DS0000013963.V367005.R01.S.doc Version 5.2 Page 9 The Inspector remains confident that the home continues to appreciate the need for comprehensive assessments due to the complex needs of the people it supports. Bevern View continues to provide one respite placement to support individuals and their families who live in the local community. At the time of the inspection, the respite place was filled by a young lady who regularly uses the service and there was evidence of a detailed support plan in place for her. Residents and staff benefit from the regularity of respite cases which enables all parties to get to know and understand each other. DS0000013963.V367005.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is excellent. This judgement has been made using available 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 three residents revealed that staff understanding and practices are a reflection of the high standard of care planning at Bevern View. The care plans viewed comprehensively outline the care needs of the individual in a way that is both accessible and person centred. Three staff members spoken with confirmed that care plans are DS0000013963.V367005.R01.S.doc Version 5.2 Page 11 integral to the way they work and this is echoed by the fact that they are kept in residents’ bedrooms. It was entirely 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 is in the process of making further improvements to the care planning system and the newly written assessment sheets 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. Each care plan inspected contained individual goals and actions for the resident to enable them to achieve maximum well-being whilst either developing or maintaining their skills. Each action is backed up by detailed guidelines that explain how staff should support residents in order to achieve that aim. Actions are monitored 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 demonstrated that they know how they should provide support. There was documentary evidence that care plans are regularly reviewed. The person centred plans are described in the home’s Annual Quality assurance Assessment (AQAA) as “a living document and is amended when something changes and thoroughly updated once a year with a review including the residents ‘Circle of Friends’.” The information viewed at inspection supported this assertion and person centred plans were found to be detailed, focused and adopt a multi-disciplinary approach. A range of detailed risk assessments are in place for each 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. One profoundly disabled resident expressed a wish to ride in the side car of a motor bike – through the process of carefully research and risk assessment this dream came true. 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 meaningful and fulfilling lives. It is noted that if rights have to be limited for the safety and well-being of residents these are fully documented and agreed with resident. DS0000013963.V367005.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): 11, 12, 13, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are appropriately supported to lead busy and fulfilling lives and to develop their educational and social skills. Residents have the opportunity to be involved in the planning and preparation of their own balanced and nutritious meals. EVIDENCE: On arrival at the home, it was immediately evident that the residents at Bevern View lead active and fulfilling lives. At 10:50am, two residents had already gone out sailing for the day, one was at school and another resident was preparing for a trip home with his mother. The other four residents were involved in an in-house programme of activities, including cooking and massage sessions. DS0000013963.V367005.R01.S.doc Version 5.2 Page 13 The activity planner that is on display provides evidence that each resident has an activity timetable that enables them to participate in a range of appropriate and fulfilling activities. The philosophy of this service, as reflected in the AQAA is to enable residents to take part in activities that are “appropriate to their age and culture” and to ensure that “they are part of the local community”. The information provided by the weekly timetable, care plans, observation of residents and discussion with staff and relatives revealed that residents continue to access a wide range of educational 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, churches, 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 also able to respond sensitively if a resident wishes to do something different. 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. There was also evidence that one parent had joined a resident and staff for an annual holiday. Conversation with one relative confirmed that they are always made to feel welcome and stated “[residents’ name] has lots of friends and the home facilitates contact and visits”. This relative also provided feedback that “whatever the resident wants to do, they always come first …. the home really tries to become part of the community”. Each resident has their own bedroom and it was observed that staff respect their private space by knocking on doors before entering and giving residents the time and space to relax quietly if they wish. Due to the complex needs of the people living at Bevern View the majority of residents rely on staff support to help them mobilise around the home. It was noted that staff were entirely engaged with residents at all times during the inspection and supported them to move as they wished. For those residents that are able to self-mobilise they were seen to move freely about the home. Due to complex healthcare needs, only four of the residents living at Bevern View are able to eat meals orally. Nonetheless, the lunchtime meal was observed to be a social occasion and all people were supported to be included at this time. For those individuals that do eat food, a four weekly rolling menu is in place. The menu is drawn up in consultation with residents to reflect the DS0000013963.V367005.R01.S.doc Version 5.2 Page 14 meals they wish to have, along with staff knowledge about their likes and dislikes. The AQAA confirmed that a recent improvement in this area is involving residents in the purchasing of food at local supermarkets. At the time of the inspection, four residents were observed to be involved in the preparation of the lunchtime meal. The menus seen include a range of varied and wellbalanced meals. DS0000013963.V367005.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are protected by the skill, knowledge and expertise of those who support them and benefit from the provision of personal and healthcare support that fully reflects their wishes and best interests. Medication is managed well at Bevern View. EVIDENCE: The residents at Bevern View are entirely dependent on staff to support them with their complex range of personal and healthcare needs. Care plans provide detailed guidance for staff as to how support should be delivered and the Inspector observed care to be provided in a discreet, dignified and respectful way. Each resident has a fully endorsed health action plan in line with the ‘Valuing People’ recommendations. There is documentary evidence of a multidisciplinary approach to health support and the support plans in place evidence working relationships with doctors, physiotherapist and speech and language therapist. Residents are regularly weighed. DS0000013963.V367005.R01.S.doc Version 5.2 Page 16 The Inspector was especially impressed with end of life plan in place for one resident that has fully considered the implications of the Mental Capacity Act in respect of the right for individuals to refuse treatment. The service is congratulated for its proactive approach to care in this respect. The home has a dedicated Health Care Advisor (RGN) who provides advice and training to staff. As Bevern View is not registered as a nursing home, nurses are not able to practice as ‘nurses’ in the care home. Due to a shortage of external resources, the home has experienced difficulty in securing the appropriate specialist training for staff without breaching their registration category. The way the home and in particular the Registered Manager have managed this situation is of utmost testimony to their professionalism and drive to get things right for the people they support. Systems are in place to ensure medication is managed appropriately. Staff receive appropriate training in the management of medication. Each resident has their own medication cupboard and a safe for creams and topical treatments. The medication for three residents was case tracked and the storage, recording and administration methods were judged to be good. The home has a general medication cupboard for storing ‘overstock’ and this includes a cupboard that is suitable for the storage of any controlled medication should it be necessary. It was suggested that the home introduce a book to record the returning of medication. As the service agreed to implement this system a requirement has not been made. DS0000013963.V367005.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and visitors to the home benefit from and are protected by, the open culture at Bevern View. EVIDENCE: The home has a complaints procedure in place that is accessible to both residents and visitors. No complaints have been referred to the Commission and all of the issues raised with the home have been dealt with appropriately. The home seeks to operate an open culture where issues are openly discussed and opinions shared. As such, since the last inspection the home has adopted a policy of recording every comment received as a potential complaint or concern. It is evident that this policy has made people feel valued and has proved to reduce the escalation of minor issues by resolving them professionally at the outset. The relative spoken with confirmed that they felt confident to raise any issue or concern with the home knowing it would be resolved. The home has a number of systems in place to protect residents from abuse. All staff have either attended or are booked to attend training in the safeguarding of vulnerable adults and it was evident from discussions with staff that they are clear about their roles and responsibilities in the protection of vulnerable adults. New staff are employed subject to robust recruitment DS0000013963.V367005.R01.S.doc Version 5.2 Page 18 procedures and the necessary checks were found to be being undertaken. The home employs an independent accountant to audit residents’ monies. DS0000013963.V367005.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a homely, safe and comfortable environment. Current plans to expand the premises will further meet their needs and provide increased personal space. EVIDENCE: The Inspector undertook a partial tour of the home, which included the communal areas and four bedrooms. The home was found to be clean, tidy and hygienic throughout. Bevern View is a purpose built bungalow that is located in the quiet village of Barcombe. Resident accommodation comprises of eight single bedrooms and a variety of communal spaces including a sensory room. The layout of the home provides two ‘wings’ each with a large kitchen/dining/lounge area. It was however observed that people tend to congregate in only one of these ‘wings’. The home is decorated and furnished to a high standard and is surrounded by DS0000013963.V367005.R01.S.doc Version 5.2 Page 20 pleasant external space. The home provides adequate aids and adaptations to meet the physical needs of the people who live there. At the end of the inspection the Responsible Individual met with the Inspector to share some proposals about a planned project to further improve the environment at Bevern View. The Trustees are currently considering architectural designs for two potential models – both of which will significantly increase the amount of private space each resident has and will also include an on site hydrotherapy pool. DS0000013963.V367005.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available 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. Feedback from a relative stated that “they are a very caring bunch of staff who do more than they are required” Discussion with staff and the Registered Manager confirmed that typical minimum staffing levels provide six staff in the morning, five staff in the afternoon and two waking night staff. All parties also confirmed that staffing levels were flexible according to needs and activities. The rotas viewed reflected these figures as accurate and all parties spoken with believe that current staffing levels are sufficient. DS0000013963.V367005.R01.S.doc Version 5.2 Page 22 Discussion with four staff and examination of three 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 the correct documentation and checks being in situ. Discussion with staff and the Registered Manager identified that a previous influx of new staff commencing employment at the same time put a strain on the induction process and in particular made it impossible for new staff to work in a supernumerary capacity. It is positive that the home has learnt from this experience and has already implemented a new process which will secure better outcomes in the future. Staff have access to a raft of mandatory and specialist training including; fire safety, first aid, safeguarding, manual handling, communication and posture management. 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. The Registered Manager confirmed in the AQAA that 60 of the staff team have either completed or are working towards a National Vocational Qualifications (NVQ) in care to at least level two. 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 month. DS0000013963.V367005.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is excellent. This judgement has been made using available 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 and effectively. . The organisation has excellent systems in place to self-audit and implement improvements. EVIDENCE: The Registered Manager is an experienced practitioner with over thirty-five years experience of working in the learning disabilities sector. She has completed the Registered Managers’ Award and is in the process of completing NVQ Level 4 in Health & Social Care. Through the completion of the AQAA, observation and discussion of practice during the inspection and feedback from DS0000013963.V367005.R01.S.doc Version 5.2 Page 24 staff and relatives, it is evident that this individual has the skills and ability to manage the service effectively in an open and transparent way. The home has an excellent system for assessing its own standards of quality which includes the annual surveying of stakeholders. Each month an independent person visits the home and audits the home against key areas, from which the service is internally graded and action plans set. The rolling plans for improvement in so many areas, some of which have been highlighted in this report evidence the service’s commitment to providing a progressive service. The AQAA provides evidence that the home has various robust 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 fully inspected on this occasion. DS0000013963.V367005.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 4 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 X 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 3 X LIFESTYLES Standard No Score 11 3 12 4 13 4 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 4 X X 3 X DS0000013963.V367005.R01.S.doc Version 5.2 Page 26 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 DS0000013963.V367005.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection 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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