Care Home: Chesfield House

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What the care home does well The home ensures it can meet residents` needs and goals before they move in. People who may wish to live there can visit and stay to check if they like it. Each person using the service has a care plan that they help to make. Plans show their needs, wishes and goals and the support they need to meet them. Residents are enabled to lead active and interesting lives and to be part of the local community. People are also encouraged to make decisions and choices about what they do each day and their meals. Their individuality is respected. Staff provide residents with good support to meet all their personal and health care needs. They also manage their medicines safely in the home for them. The home is in a good place for people to walk to shops and use other services in town. The house is very comfortable, well kept, clean and safe. Residents` bedrooms are nice and personal and they choose the decor and furnishings. Staff are very well trained which helps them understand people`s special needs and know how to support them and keep them safe. Necessary checks aremade on all staff to make sure that they are suitable to do work caring for people. The home is well run by a manager with suitable skills and experience. Staff have good support and work well as a team to offer individual care. There are ways of checking the service is right and continues to improve for residents. What has improved since the last inspection? This does not apply because Chesfield House is a new home and so the service has not been inspected before. What the care home could do better: It will be good when care plans are made in a way that individual residents can understand better so they can be sure their preferences and goals are known. CARE HOME ADULTS 18-65 Chesfield House 112 South Street Leominster Herefordshire HR6 8JF Lead Inspector Christina Lavelle Key Unannounced Inspection 14 August 2008 10:30am – th DS0000071679.V370190.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 DS0000071679.V370190.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. DS0000071679.V370190.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chesfield House Address 112 South Street Leominster Herefordshire HR6 8JF 01432 342 529 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) Inspiration Care Ltd Karen Anne Hall Care Home 5 Category(ies) of Learning disability (5), Mental disorder, registration, with number excluding learning disability or dementia (5) of places DS0000071679.V370190.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: Either Whose primary care needs on admission to the home are within the following categories: Learning Disabilities (LD) 5 Mental Disorder (MD) 5 The maximum number of service users to be accommodated is 5 N/A (First inspection) 2. Date of last inspection Brief Description of the Service: Chesfield House was registered as a care home on 13 March 2008. The manager and responsible individual for the provider company, Inspiration Care Ltd, is Ms Karen Hall. The home provides accommodation with personal care for up to five adults. This can include respite care or an emergency placement, depending on room availability and if it can provide necessary support. People using the service must require care because of learning difficulties or a mental health disorder and may use behaviours that can challenge the service. People living or staying at the home are therefore likely to have high support needs. One of the main stated aims of the service is “to encourage the people living at Chesfield House to achieve their maximum potential in social skills and everyday living skills so that they may live as independent a life as possible”. The home is situated on a main road a short walk from the centre of the town of Leominster. Public transport, shops and other facilities and services are also easily accessible. The house is large and detached and was formerly a bed and breakfast business, which has been converted to a high standard. The home consists of three self-contained units (one is on the ground floor) and two ensuite bedrooms. Each bedroom has either an en-suite shower/wet room or a bathroom. There is a sitting room, dining room, kitchen, storage space and utility room for everyone to use and a separate staff sleep-in room and office. Information about the service is provided in a statement of purpose and service user guide, available from the home. The fee and other costs are set out in a Service Agreement issued to individuals prior to their admission. This is agreed with them, their advocate (if appropriate), the home and the funding authority. DS0000071679.V370190.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means that the people using this service experience good quality outcomes. This is a key inspection of the service provided at Chesfield House. This means all the Standards that can be most important to people living or staying in care homes are assessed. As part of the inspection we, the Commission, visited the home without telling staff or residents beforehand. We spoke to a resident about the home and their lifestyle. One of the care staff was asked about their role, training and support and the manager explained how the home is run. Surveys were sent to the home for residents and staff asking their views of the service. Seven surveys were returned and their feedback is referred to in this report. The manager had also completed an AQAA (annual quality assurance assessment) form, which is now required. This asks the manager to say what their service does well, could do better and about their plans to improve the service. Some relevant records, including resident’s care plans and staff records, were checked and we looked at the house. We also considered all other information received by the Commission about the home since it was registered, including notifications about events that had affected people at the home. What the service does well: The home ensures it can meet residents’ needs and goals before they move in. People who may wish to live there can visit and stay to check if they like it. Each person using the service has a care plan that they help to make. Plans show their needs, wishes and goals and the support they need to meet them. Residents are enabled to lead active and interesting lives and to be part of the local community. People are also encouraged to make decisions and choices about what they do each day and their meals. Their individuality is respected. Staff provide residents with good support to meet all their personal and health care needs. They also manage their medicines safely in the home for them. The home is in a good place for people to walk to shops and use other services in town. The house is very comfortable, well kept, clean and safe. Residents’ bedrooms are nice and personal and they choose the decor and furnishings. Staff are very well trained which helps them understand people’s special needs and know how to support them and keep them safe. Necessary checks are DS0000071679.V370190.R01.S.doc Version 5.2 Page 6 made on all staff to make sure that they are suitable to do work caring for people. The home is well run by a manager with suitable skills and experience. Staff have good support and work well as a team to offer individual care. There are ways of checking the service is right and continues to improve for residents. 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. DS0000071679.V370190.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 DS0000071679.V370190.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 this visit to the service. People who may wish to use this service can be confident the home would be able to support them. This is because a comprehensive assessment is made of their needs and home staff would know their wishes and goals from involving them and/or their representative in their needs assessment and admission. EVIDENCE: It was confirmed through discussion with the manager and one new resident and from their care records, that people are not admitted to the home until a full needs assessment is undertaken. The home also obtains information about any potential residents from the referrer and other involved professionals and has a copy of their community care assessment. Ms Hall then arranges to visit and meet them at their current residence and completes the home’s own initial assessment. They are also given the information documents about the service. Introductory visits to the home are arranged with the individual’s family and/or representative. A keyworker from the care staff team is allocated to facilitate their visits and they can choose from available bedrooms. Individuals are then involved in setting up a care plan, which include their likes, dislikes and goals. Overnight and a trial stays follow with reviews held at six weeks and three months. Compatibility with other residents is considered and a care plan and contract agreed and signed by all parties before their placement is confirmed. DS0000071679.V370190.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. Each resident has a care plan they and/or their representatives are involved in making and reviewing. Plans show their needs and goals and how they can be met. Risks are also assessed so they can be minimised. People make choices and decisions about their lives and staff promote their rights and individuality. EVIDENCE: People using the service all have a care plan showing their needs, skills, likes, dislikes and aspirations. Plans include targets, actions and resources needed to achieve them. The home has an appropriately “person centred” approach to care planning, which means that individuals are involved in planning their own care and are supported and encouraged to make choices and decisions in their daily lives. It is good the home proposes to give residents a copy of their plan in a suitable format. Plans were seen to cover all relevant areas of people’s lives and had been agreed with them and their family or representatives. They address their individual, different needs and are reviewed regularly. Residents say they attend their reviews and choose their routines, food and activities. DS0000071679.V370190.R01.S.doc Version 5.2 Page 10 There is a keyworker system operated by the home, whereby the care staff are allocated to particular residents. They can give them some individual support with such as their shopping, activities and outings and take an active part in reviewing and updating their plans. Staff are clear about their keyworker role and one comments that the home has “Good thinking about person centred plans and forward planning for care”. Staff also confirm in their surveys that they are always given up to date information about the residents’ needs. Each person’s plan includes comprehensive risk assessments. The AQAA states “staff support and enable the service users to take responsible assessed risks”. Plans also cover risks associated with medical conditions, an individual fire risk assessment and detailed plans for managing behaviours that can be aggressive and/or challenging. They include techniques described such as de-escalation and for physical interventions if the person or others are being placed at risk. Records are kept of all incidents with details of any interventions used by staff. The manager is aware of the implications when limitations on their choices and freedom have to be placed on individuals for their safety and welfare. In these circumstances decisions have been agreed with relevant professionals and in one instance when a resident was not able to make an informed decision an Independent Advocate was sought, as per the Mental Capacity Act. DS0000071679.V370190.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, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. People using the service are enabled to take part in appropriate activities that meet with their personal interests. The home supports them to be part of their local community and to keep in touch with their family and significant others. Independence is encouraged and their daily life choices, dignity and rights are respected. Food provided is healthy and meets their needs and preferences. EVIDENCE: Plans include each resident’s social and recreational interests and also focus on developing their independent living skills. Whilst it may be difficult for some people to take up educational or work related activities because of their high support needs, staff seek and would facilitate such opportunities. It is good that one person is soon to start an animal care course. Residents take part in a wide variety of activities and efforts are made to involve them in the local community. Staff support is provided and rotas are flexible to facilitate this. DS0000071679.V370190.R01.S.doc Version 5.2 Page 12 People can have some one to one support from their keyworkers and have day trips out and an annual holiday of their individual choice. Local events, courses and invitations etc. are displayed on the home’s notice board. Detailed daily records are also kept of all their activities and community participation. Staff encourage residents’ involvement in domestic routines and the day to day running of the home. Meetings are held when they can choose menus, discuss group activities and any other house related matters. They choose their own daily routines, one person confirming that they get up, have meals and go out whenever they want to. They all have a key to their own bedroom and staff were observed to respect residents’ privacy such as by knocking on their doors and how they spoke and interacted with them. Individuals are also assessed in respect of self-management of their money and medication whenever possible. Residents are supported to maintain their links with their families, friends and significant other people. The AQAA states that the home offers open access (no visiting times) and welcomes visitors in private or in a chosen communal area. Family and friends are also encouraged to participate in daily routines. Regarding food provided by the home menus reflect varied and healthy meals that residents like and meet their dietary needs. The manager has experience and is very knowledgeable about these special diets and has instructed staff and provided written information for them. Staff promote healthy eating and aim to ensure that such as fresh fruit and vegetables, cereals and yoghurts are always available. Individual food records are kept and there is a weekly menu and a generic four-week menu that residents have input to. They are also able to have their meals at their preferred times and in their bedroom if they wish. One person also told us they are involved in shopping and preparing meals. DS0000071679.V370190.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 good. This judgement has been made using available evidence including this visit to the service. Residents receive personal care from staff in the ways they need and prefer. Their physical and emotional health care needs are met because the home has procedures in place that staff follow. If people take medicines that they are not able to manage themselves then staff manage them safely on their behalf. EVIDENCE: Residents’ plans have detailed information about their health and the personal support each person needs and they state that self-care should be encouraged. They include people’s preferences and individual, specialist needs. Checklists are kept of the personal support that people have received and of any health related checks such as weight and blood sugar levels. In addition their moods and behaviours are recorded as part of monitoring their emotional well-being. The home obtains as much information about people’s medical history as they can before they move in. Each resident has a medical information file, which includes individual protocols and procedures to manage their condition better. Records are kept of routine, preventative and specialist health care input from GPs, occupational therapist, foot care and from a Consultant Psychiatrist etc. DS0000071679.V370190.R01.S.doc Version 5.2 Page 14 Regarding medication prescribed for residents the home has a comprehensive policy and procedures to ensure its safe management. This includes protocols for medicines that can be administered as and when required when people are anxious and/or use aggressive behaviours. Staff closely monitor all medication and possible side effects. Individuals are assessed and would be supported to manage their own medicines if capable. Staff are currently responsible for managing medicines in the home and staff designated to do so have received relevant training. Sample of these staff signatures are kept and records seen of medicines administered are being maintained appropriately. Suitably secure storage is provided for medicines in the home. Information is available about prescribed medications in Patient Information Leaflets and from the internet. Weekly audits of medication are undertaken to ensure good stock control. DS0000071679.V370190.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 this visit to the service. If people have concerns about the service they and their representatives know how to complain and can be confident they will be listened to and dealt with. The home safeguards people living there from abuse, neglect and self-harm. EVIDENCE: The home provides a clear complaints policy that is included in the service user guide, a copy of which is given and explained to all the residents and is also in a suitable pictorial format. Complaints made would be dealt with in a specified time frame and the home has a complaints log to record complaints received which would detail the investigations and outcomes. However no complaints had been received by the home or us, or referrals made under safeguarding procedures, since the home opened. Residents are also encouraged to express their views and concerns in their house meetings, when notes are produced and evidence of any actions taken is recorded. One resident says that they feel able to raise any worries with the manager and staff and staff confirm they would know what to do if anyone raises concerns about the home with them. The home also provides policies and procedures for recognising and responding to suspicion, allegation or evidence of abuse, adult protection, whistle blowing and has a copy of the local authority multi-agency safeguarding procedures. Staff receive training on abuse and protection and how to use the procedures as part of their induction in addition to their training on physical interventions. DS0000071679.V370190.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including this visit to the service. People living or staying at Chesfield House have a safe and well-maintained home that is homely, very comfortable, clean, pleasant and hygienic. EVIDENCE: Chesfield House has a very convenient location near to Leominster town, with shops, services and facilities within easy walking distance. It is also on a main bus route. The accommodation has been converted to a care home with very good quality decor, furnishings and fittings. The garden is quite small but it is private and enclosed and has been landscaped to offer a pleasant area. The overall impression of the environment is homely and very comfortable and it is good that residents are supported to choose their own colour of decor, soft furnishings, pictures etc in their bedrooms. The bedroom of one permanent resident is very well personalised and they are clearly very proud of it. Three bedrooms are self-contained with cooking hobs, fridges, microwaves, toasters and kettles to meet the service’s aim of encouraging independent living skills. DS0000071679.V370190.R01.S.doc Version 5.2 Page 17 All areas of the house were visited by us and found to be warm, fresh, clean and tidy. There are appropriate laundry facilities and the home has produced a comprehensive infection control policy and staff cover this topic as part of their induction. The home also follows required food safety regulations and provides equipment such as alcohol wipes, disposable gloves and aprons. There are suitable arrangements in place for the disposal of soiled waste. . DS0000071679.V370190.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 this visit to the service. Residents receive appropriate support and their needs are met because there are enough, competent and well trained staff. They can also have confidence in staff because checks have been carried out to make sure they are suitable. EVIDENCE: The home has gradually recruited a stable staff team, with a wide age range and gender mix. Staff rotas are flexible and are based on residents’ support needs and their daily activities. There are two care staff teams, each with a senior, and staff confirm there is always enough staff on duty, with managers providing any additional support needed. Staff all have a clear job description that defines their role and responsibilities and are given a staff handbook. Management place a high level of importance on staff training and one of the home’s directors is a qualified trainer in many care, health and safety related areas including mental health awareness, risk assessment, epilepsy, fire safety and moving and handling. Staff surveys confirm they receive training relevant to their role, one says “Training is always ongoing and provided when needed and any we would like to attend Inspiration care will try to accommodate”. DS0000071679.V370190.R01.S.doc Version 5.2 Page 19 Staff also have opportunities to achieve social care qualifications. They have all completed an accredited induction programme LDQ (Learning Disabilities Qualification) and over half the team already have an NVQ (National Vocational Qualification) and the rest are currently working towards an NVQ. The home has a robust recruitment policy and procedures, which are followed in practice. Staff confirm they had an enhanced CRB (criminal records bureau) check and written references taken up before they started work at the home and the AQAA states that the home has obtained satisfactory checks for all its staff. Staff records were sampled and contain relevant documents and checks, although the manager was advised that applications should now include their full employment history, with any gaps explored and explained. It is also good that a recently appointed staff member discussed how one resident had been involved in their interview and selection. Staff report that their induction to the home was very thorough, one comments an “excellent induction. One of the best inductions I have received”. They also regularly meet with their manager for support and to discuss how they are working and feel there is good teamwork and communication, resulting in good outcomes for people using the service. Their comments include “Staff all want the best for service users and so work together well” and “All members of staff work together as a team to give the best possible care to our residents”. DS0000071679.V370190.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. People can have confidence in the service because the home is well managed. There are ways to ensure the service continues to improve and people’s views should inform how it is reviewed and develops. The environment is safe for the residents and staff as good health and safety practices are carried out. EVIDENCE: The manager Karen Hall has 18 years care experience, seven of these working with people who have learning disabilities, mental health disorders, challenging behaviours and complex needs. Ms Hall has an NVQ level 4 in health and social care, a registered manager’s qualification and completed other relevant training including adult protection, risk assessment, supervision, disciplinary, recruitment and selection procedures, person centred planning, accident and incident reporting, all mandatory heath and safety topics as well as attending many specialist courses such as autism, epilepsy and mental health. DS0000071679.V370190.R01.S.doc Version 5.2 Page 21 Ms Hall has a clear understanding of the key principles and focus of the service and plans to continually improve it and to promote residents quality of life and provide them with good individualised support. Management are supported by a strong staff team who also support the principles of person centred care. The AQAA contains clear relevant information with good evidence of what the home does well and about their plans to continue to make improvements. This is part of an effective system for monitoring and assuring service quality. An independent person makes the required monthly monitoring visits to the home with a written report made following each visit on the conduct of the home. An annual service review and of all the home’s polices and procedures are planned that will result in development plans with actions identified. It is also planned to produce a questionnaire for people who are using the service, their family and involved professionals, as their views should inform service development. Regarding the promotion of health and safety in the home, all staff receive training in mandatory areas including fire safety, first aid and food hygiene. It was confirmed during the service’s registration process that the property has a Building Control certificate, including suitable fire safety precautions and a fire risk assessment. The AQAA also confirms that relevant certificates for gas appliances, electricity and appropriate risk assessments are in place and that fire and other safety checks and tests are carried out as required. Staff at the home also work to a comprehensive health and safety policy and procedures. DS0000071679.V370190.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X DS0000071679.V370190.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NA STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered persons meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered provider 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 providers to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000071679.V370190.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 DS0000071679.V370190.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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