Care Home: Bunyan Lodge

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What the care home does well The AQAA had been completed in detail and confirmed to us that the service were aware of their strengths and weaknesses and had a plan for the coming year that would continue to improve the lives of those living and working at Bunyan lodge. People using the service were respected by the staff and supported to live as they wished, in a safe environment. Each resident was provided with a welcome pack that gave full details of the home, including information about what was provided and when things happened. Wherever possible new users of the service were given the opportunity to visit the home prior to moving in. Staff included the people living at Bunyan Lodge in the process of planning care to ensure that the care delivered was person centred. Seven of the 10 people living at the home who completed a questionnaire took the time to tell us how well they were treated by the staff and who they would speak to if there was a problem. If a name was mentioned it was always that of the acting manager, who was obviously greatly appreciated. One person stated "I gratefully help staff with jobs". There were robust systems in place for the ordering, storing and administration of medication. Staff had been recruited correctly and we were confident that those working at Bunyan Lodge had had the necessary pre-employment checks and references taken up before being offered a position. Although the ethnicity of the staff team did not reflect that of the people using the service we saw that peoples religious and cultural needs were being met as required. What has improved since the last inspection? The practice of people queuing for medication had ceased and prescribed medications were now offered to people where they were at the particular time of day the medication was due.Care plans were in place for all assessed needs, so staff knew the support that needed to be provided to meet the needs of the people living at the home. CARE HOME ADULTS 18-65 Bunyan Lodge 66/68 Kimbolton Road Bedford Bedfordshire MK40 2NZ Lead Inspector Sally Snelson Key Unannounced Inspection 10th September 2008 10:40 Bunyan Lodge DS0000014994.V372081.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 Bunyan Lodge DS0000014994.V372081.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. Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bunyan Lodge Address 66/68 Kimbolton Road Bedford Bedfordshire MK40 2NZ 01234 346146 01234 342557 admin@apexcare.co.uk marilyn@apexcare.co.uk 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) Apex Care Homes Limited Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (15), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (15) Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th June 2007 Brief Description of the Service: Apex Care Homes LTD owns Bunyan Lodge residential care home. The home provides care to fifteen people with mental health needs. The accommodation is across two Victorian semi-detached houses and consists of a dining room, an office, and a kitchen. The basement has a games room, laundry, and storeroom. The home has fifteen single rooms, which are located on the first and second floors, with shaft lift access. People who wish to smoke do so outside the home. The rear of the house has an attractive garden and a patio area. The front of the house has a small driveway with limited parking facilities. The home is situated in a residential area close to the town centre with its amenities and good bus and train services. The fees for this home vary to up to £700.00 per week, depending on the funding source and assessed need of the person. Additional charges are made for hairdressing, barber services, holidays, toiletries and newspapers. Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which requires review of the key standards for the provision of a care home for younger adults that takes account of residents’ views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. The inspection was a key inspection, was unannounced and took place from 10.40 am on 10th September 2008. We used an expert by experience who spoke to four people who were using this service and also toured the building. An expert by experience is a person who either has a shared experience of using services or understands how people in this service communicate. They visited the service with us to help us get a picture of what it is like to live in or use the service. This is important because the views and experiences of people who use services are central to helping us make a judgement about the quality of care. The manager’s post is currently vacant. The owner was interviewing prospective candidates on the day of the inspection. The previous manager had resigned at the beginning of the year, since when a member of staff with a Registered Managers Award (RMA), but who did not wish to apply to be the registered manager, had been supporting the owner to run the home. Earlier this year the owner believed she had found the correct person to manage the home but for personal reasons this person did not eventually take up the post. Although it has been a difficult time the home has coped really well and the owners were keen to employ the correct person into the role of manager. During the inspection the care of three people who used the service (residents) was case tracked. This involved reading their records and comparing what was documented to what was provided. We also looked at recruitment, training health and safety documentation, medication records and food planning as well as touring the building. Any comments received about the home, plus all the information gathered on the day was used to form a judgement about the service. Three staff members and 10 service users had completed surveys, and the owner and the acting manager had completed an AQAA in advance. Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 6 We would like to thank all those involved in the inspection for their input and support. What the service does well: What has improved since the last inspection? The practice of people queuing for medication had ceased and prescribed medications were now offered to people where they were at the particular time of day the medication was due. Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 7 Care plans were in place for all assessed needs, so staff knew the support that needed to be provided to meet the needs of the people living at the home. 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. Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 People who use this service experience good quality outcomes in this area. Each resident was provided with a welcome pack that gave full details of the home, including information about what was provided and when things happened. This meant that residents, and prospective residents, knew what they could expect from living at Bunyan Lodge. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home had a statement of purpose that was kept updated and reviewed regularly. Each resident was provided with a welcome pack that gave full details of the home, what and when things happened, and what they could expect from living at Bunyan Lodge. Staff intended that people living at the home would become more involved in providing information for the welcome pack. There was evidence that staff used any supporting information from other sources, such as Care Management Plans, plus the information they gained from visiting a prospective resident prior to admission, to make the decision that Bunyan Lodge was able to meet their needs. All this information was used to formulate initial key plans of care. Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 10 Discussion with the provider indicated that staff continually assessed people living at Bunyan Lodge and would support them to move to alternative placements if this was in their best interest. Staff remained in contact with many of the people who had moved on from Bunyan Lodge. Wherever possible new users of the service were given the opportunity to visit the home prior to moving in, and in some cases the planned move was a slow process, with more than one introductory visit to the service. All people living at Bunyan Lodge had a contract with the home that was signed by them and a senior member of staff. Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 People who use this service experience good quality outcomes in this area. Staff included the people living at Bunyan Lodge in the process of planning care. This ensured that the care delivered was person centred. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During the inspection we looked in detail at the care plans of three people living at the home and also looked at how the care described reflected the care delivered. People using the service had clear, well-written plans of care, had clearly identified a need, a goal, and how staff were to support the need. Care plans had been kept under review every three months and were altered as care needs changed. It was apparent from the way that care plans had been written that the people using the service had been involved in their care plans, and were supported by staff relatives or advocates to make decisions. Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 12 Residents had open access to staff and were welcomed into the office area and were able to influence the running of the home. Management met regularly with residents to discuss the way the home was run. A number of the people living at the home had influenced the decoration of the home, the planning of holidays, and the running of the summer fete; due to take place the weekend following the inspection. Wherever necessary staff identified risks, and planned with the resident how these could be minimised. These risks usually centred on behaviours such as smoking, or staying in bed, and there was evidence that the person using the service was provided with sufficient information to make an informed decision about risk. The discussions were documented and used to inform risk assessments. In each care plan there was a photograph and a description of each resident that could be used if a person became missing from the service. We were informed that this procedure had been put to use the evening of the fete, when a service user was found to have gone missing. While speaking to people using the service we asked if they believed that information about them was held in confidence. No one had any concerns about this and all felt that they could trust staff. Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,15,16,17 People who use this service experience good quality outcomes in this area. People who use the service were supported to make choices and to pursue the lifestyle that they wished. Staff respected people’s human rights and treated them as individuals. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Many of the people living at Bunyan Lodge attended day centres both externally and within the company, either Monday to Friday or part of the week. Other people went out to the town and visited places of interest or spent time with friends, while some chose to stay around the home most of the time. Some people had joined clubs and enjoyed activities such as swimming or yoga, or had taken up some form of voluntary work within the community. Some of the people living at Bunyan Lodge were keen to be useful around the home and liked to help staff with some of the chores. Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 14 The staff had worked with the people living at the home and their relatives and friends to ascertain what they enjoyed doing, and where they would like to go for day trips and holidays. This ensured that the activities arranged were what people wanted. Decisions were made as part of regular residents meetings and people living at the home had the opportunity to put forward opinions and ideas. Two people living at Bunyan Lodge had had a break on a barge on the Norfolk Broads and most of the others had recently returned from holiday at a hotel on the Isle of Wight. Although this holiday to the Isle of Wight had become an annual event, residents insisted it was where they wanted to go. Recent day trips included trips to the Shuttleworth collection, Linton Zoo and the Moscow State Circus. People attended church services as they wanted, and one service user told us about the support he gained from a church group. A member of staff had accompanied a resident on a visit to a Buddhist temple. The owner was investigating the possibility of providing ‘a flat’ and staff support for a person preparing for independence. The owner was keen to do this as the barrier for the resident was a fear of being ‘dumped in the community’. The owner would need to discuss options with the registration team. A choice of meals was available, and menus were displayed within the home. All people said that they enjoyed the meals in the home. People also confirmed that they were able to make themselves drinks and snacks, and now had a greater access to the kitchen area. Some people were helping with meal preparation and were making cakes etc as part of a planned activity. Bunyan Lodge DS0000014994.V372081.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): 18,19,20,21 People who use this service experience good quality outcomes in this area. The home had built good links with health staff and would support people living at the home to make healthy choices. Medications procedures were adhered to precisely and provided excellent outcomes for people. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: At the time of the inspection there were 14 people living at Bunyan Lodge. The one vacancy was as a result of a recent bereavement. We were told that those who wished to be would be supported to attend the funeral, and that the deceased person continued to be spoken about within the home. Few of the people living at Bunyan Lodge needed assistance with care continually, but many needed prompting and intermittent support. At the time of the inspection none of the people using the service had nursing needs. In the past when people had nursing needs the community nurses had supported these. Community Psychiatric Nurses (CPN’s) were frequent visitors Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 16 to the home and staff had good relationships with them, and the GP’s, and consultants, involved in residents care. Staff encouraged people to regularly attend health screening and health appointments, including opticians and dentists. The medication policy described how people would initially be assessed to self medicate. Currently no one was completely self-medicating but some people were able to administer certain of their medications, or be supported to manage their medications. The medication record sheets (MAR) in the home were excellent and provided a clear audit trail. All of the medications that we checked reconciled, and it was clear that staff were vigilant about signing medications into the home, administering and storing medications and returning unused medicines. Bunyan Lodge DS0000014994.V372081.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 People who use this service experience good quality outcomes in this area. The home had an ethos that allowed people living there to make complaints, and to be protected from any forms of abuse. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We had not received any complaints about the home since the last inspection, and neither had there been any complaints made to the staff or management. All of the people using the service who returned questionnaires, and those who we spoke to, stated that if they were unhappy they would talk to a member of the staff, many named the acting manager as the person they would confide in. We felt confident that if the complaint involved staff there was enough information to direct people to other agencies who could help. Discussion with the acting manager confirmed that she was aware of the need to document any complaints and also to document the investigation process that was undertaken when dealing with a complaint. A copy of the local guidance in Safeguarding adults was noted to be in place alongside a procedure on abuse. This described the types of abuse and what staff must do if they suspected any abuse of someone living at the home. Training records, and staff through discussion, confirmed that they had received training in this area. The owner remained a member of the local Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 18 safeguarding board. We had received appropriate notifications of a range of incidents affecting people using the service and we were confident that any safeguarding referrals were correctly made. Since the last inspection a comment made by a person using the services instigated a safeguarding meeting and a thorough investigation of financial procedures in the home, particularly the way resident’s personal monies were handled and used. As part of the investigation we carried out a random inspection on 23rd August 2007, and as a result we took documentation from the home that was given to the police to investigate. The police passed the information to the owner who was able to carry out a more detailed investigation and once again the police became involved. During this time the registered manager was suspended from her post. Subsequent safeguarding meetings and procedures confirmed that any residents involved had the situation explained to them and were given the opportunity to speak to the police. The matter has now been satisfactorily resolved and appropriate action taken. As a result the company altered the way residents money was ‘held’ by the home, how they accessed money, and how any expenditures were recorded. Bunyan Lodge DS0000014994.V372081.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 People who use this service experience good quality outcomes in this area. The home provided people with a clean pleasant well furnished environment which was homely and comfortable. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: With the exception of on-going maintenance and decoration there had been no major changes to the environment and the comments made and the last inspection remain appropriate. ‘The accommodation was provided over three floors and accessed via a passenger lift. The location and layout of the home was noted to be suitable for its purpose. Furnishings and fittings were domestic and of a very good standard. The communal areas in the home were clean and tidy and residents rooms contained personal items, which reflected their individual personalities.’ Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 20 A new wooden floor had been recently laid in the dining room. At the time of the inspection people using the service were able to smoke in designated areas of the building. The communal areas of the home were clean and free from offensive odours at the time of inspection, as were the individual rooms we visited. Policies were in place regarding infection control and hand washing facilities were sited in the areas where waste was being handled’. Collages and photographs of the holidays experienced by the people living at Bunyan Lodge were displayed in communal areas of the home, making it feel homely. We recommend that the access area to the basement is kept under review and closed off, or altered, if indicated. Bunyan Lodge DS0000014994.V372081.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): 32,33,34,35,36 People who use this service experience good quality outcomes in this area. Robust recruitment procedures, and a varied training programme, ensured that people living at the home had their needs met by a skilled staff team. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Three staff files were sampled and it was apparent that staff had been recruited correctly and had not started work until all the appropriate checks and references had been undertaken. Staff commented that they wished to try and encourage more service users to become involved in the recruitment process. The home had been accredited as an Investor in People since 1997 and placed a strong emphasis on training staff. Files indicated that staff were offered, and attended, a variety of training both internally and externally. The acting manager had clear processes to identify the staff that needed to update and revisit training (training matrix). We were pleased to note that in addition to Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 22 mandatory training, staff were attending training that related to the conditions and needs of the people living in the home. Many of the staff team had worked at the home for a number of years and were committed to providing care and support to people with mental health problems. One of the two staff who did not have at least an NVQ level 2 was currently working towards this qualification. This was commendable. The management had introduced a reward scheme for those staff who completed NVQ’s. One staff member was concerned that the cost of the NVQ training was prohibitive. We were advised that staff were asked to pay, but the money was available as a loan and at least 70 of any money spent would be paid back on completion of the course. The AQAA advised us that ‘All staff complete the Skills of Care Common Induction standards within 12 weeks of joining and are required to complete all mandatory training e.g. moving and handling, infection control, first aid, fire safety etc. as well as POVA, Person Centred Care, Mental Health Disorders. Staff are also offered training in many other areas including more recently the Mental Capacity Act, psychiatric drugs and its side effects, dealing with challenging behaviour, equality and diversity etc. Senior staff have undertaken training on the New Mental Health Act and arrangements have been made for all staff to undertake this training’. All staff had regular supervision that was recorded. The files looked at showed that supervision had taken place at least 2 monthly. Bunyan Lodge DS0000014994.V372081.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): 37,39,40,42 People who use this service experience good quality outcomes in this area. Despite only having an acting manager the home was being effectively run. The AQAA contained excellent information that was supported by appropriate evidence. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Despite the fact that there had not been a registered manager in post for a year it was being effectively run. The previous registered manager had been suspended in August 2007 and resigned at the beginning of 2008. The owner had advertised and filled the post for a new manager earlier in the year, but due to personal reasons the appointee had not taken up the post. The post Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 24 had been re-advertised and although there had been some applicants the owner had not successfully recruited to the post. An agency was now supporting this process, and it was expected that the post would be filled in the very near future. However in the meantime senior carers were acting up to some parts of the managers position, and a member of staff who had worked in the home in the past and had a Registered Managers Award (RMA), but did not want to be the permanent registered manager for Bunyan Lodge was, with the owner, overseeing the running of the home. Staff, and those using the service, spoke highly of her ability to manage the home. Quality assurance questionnaire had been sent out for the current year and notice had been taken of any points raised, but as yet a report had not been produced. People told us that if the home looked after any money on their behalf this was handled correctly and they could have instant access if they needed. Some people had agreed, as part of their care plan, to have agreed amounts of money, or cigarettes, given to them either weekly or daily to help them manage. The acting manager stated that she was reviewing policies and procedures as they were discussed, but she was aware that a new manager would want to make some procedural changes. Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 3 3 X 2 2 x 3 x Bunyan Lodge DS0000014994.V372081.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. 1 Refer to Standard YA39 Good Practice Recommendations There should be evidence that any Quality Assurance questionnaires or surveys have been reviewed and acted upon. It is expected that a report is produced annually after such an exercise. The acting manager should continue to review the policies and procedures in place to ensure that staff have the correct information to do their job and that care and support is provided in consistent way. 2 YA40 Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Bunyan Lodge DS0000014994.V372081.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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