Care Home: Cleeve Villas

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What the care home does well The service provides support for people that have complex mental health needs in a relaxed and informal environment.The staff team support people living at the home to make decisions about their life. This includes supporting them to take risks to maintain their independence and follow their personal interests and hobbies. What has improved since the last inspection? Opportunities for people to undertake activities within the community have increased along with staffing levels to enable these activities. This promotes autonomy by allowing individuals to follow their personal interests and enhance their well being. Requirements that were left at the last inspection visit that related to medication have all be met and safe medication practices were in place. This means that the staff team support people with their medication in a way that is safe. The homes policy on safeguarding adults has revised and updated to reflect current practice. Other policies had also been updated to reflect current practice and it was confirmed that this was an ongoing practice. This demonstrates that the provider and manager endeavour to keep staff informed of current practices. This ensures the welfare rights and best interests of the people living at the home are maintained. What the care home could do better: To ensure the people living at the home are protected, employment histories on staff application forms should be fully recorded. This will demonstrate that robust practices are in place to safeguard everyone living at the home. Regular staff supervision would ensure that staff are supported appropriately. This would further ensure that robust practices are in place to enable the needs of the people living at the home to be met. CARE HOME ADULTS 18-65 Cleeve Villas 69/70/71 Wilson Street Derby Derbyshire DE1 1PL Lead Inspector Angela Kennedy Unannounced Inspection 21st April 2008 09:30 Cleeve Villas DS0000061805.V362879.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 Cleeve Villas DS0000061805.V362879.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. Cleeve Villas DS0000061805.V362879.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cleeve Villas Address 69/70/71 Wilson Street Derby Derbyshire DE1 1PL 01332 383187 01283 734984 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) Cleeve Villas Care Services Limited Mr Stephen Maurice Kent Care Home 14 Category(ies) of Learning disability (14), Mental disorder, registration, with number excluding learning disability or dementia (14) of places Cleeve Villas DS0000061805.V362879.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Cleeve Villas Care Services Limited is registered to provide nursing, personal care and accommodation for service users whose primary care needs fall within the following categories: Learning disability (LD) Mental disorder (MD). Admission of one named person over 65 years of age under the category mental disorder (MD). Refers to application received on 26.1.07). The maximum number of persons to be accommodated at Cleeve Villas is 14. 23rd April 2007 2. 3. Date of last inspection Brief Description of the Service: Cleeve Villas is a late Victorian building situated within a few minutes walk of the Derby city centre. The home has fourteen single en-suite bedrooms, including one specifically for the needs of wheelchair users. The communal areas include the dining area, lounge, quiet room, kitchen, bathroom and toilets. The home provides care for service users who have mental health needs and a learning disability and are 18 years of age and over. The home has a qualified psychiatric nurse on duty 24 hours a day, along with trained care assistants. Information on fees was not available. The Registered Manager stated fees are dependant on need and arranged by the Director’s of the Company. Cleeve Villas DS0000061805.V362879.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key inspection was unannounced and took place over approximately eight hours. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with the people using the service. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. An Annual Quality Assurance Assessment (AQAA) had been completed by the service. This is a self-assessment for providers that is a legal requirement. This assessment gives the provider an opportunity to let us know about their service and how well they think they are performing. The information provided in the AQAA is reflected within this report. Surveys were sent out to some of the staff and the people living at Cleeve Villas. Three staff surveys and two surveys from people living at the home were returned. Information provided within these surveys are included in the report. At this inspection visit two people were case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at care plans and other documents relating to that persons care, talking to staff regarding the care they provide and if possible talking to the individual. Both of the people case tracked were able to discuss their opinion of the service and support provided to them. What the service does well: The service provides support for people that have complex mental health needs in a relaxed and informal environment. Cleeve Villas DS0000061805.V362879.R01.S.doc Version 5.2 Page 6 The staff team support people living at the home to make decisions about their life. This includes supporting them to take risks to maintain their independence and follow their personal interests and hobbies. 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 Cleeve Villas DS0000061805.V362879.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cleeve Villas DS0000061805.V362879.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 Cleeve Villas DS0000061805.V362879.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Before admission is agreed comprehensive assessments are undertaken. This ensures that individual’s holistic needs can be appropriately met EVIDENCE: Needs assessments were seen for the two people case tracked. As stated in the AQAA, an accurate assessment of each person’s needs was recorded, which provided the staff team with the information they needed in order for each person to be supported as required. These assessments were detailed and included all areas of individual need and recorded significant events in the individual’s life. Both of the people case tracked also had assessments that had been undertaken through social work assessment, the care management system, or psychiatric assessment. From the information gathered within the assessments, a comprehensive care plan was formulated that was person centred. This ensured that each person’s plan of care was individual to them and addressed all of their support needs, such as social, emotional, health and personal care. The assessments seen demonstrated the involvement of the individual and their representatives Cleeve Villas DS0000061805.V362879.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems in place enable the assessed needs of each person to be met in accordance with their preferences and this promoted independence. EVIDENCE: The care plans and risk assessments for the two people case tracked were looked at. The information recorded demonstrated that the staff team had clear instruction as to the support each person required, in order for their needs to be met. The care plans seen were personalised and reflected each individuals needs. As stated in the AQAA care plans included individual choices, preferences and preferred daily routines. This means that the people living at the home were able to make decisions about their lives because staff promoted their rights and choices. Cleeve Villas DS0000061805.V362879.R01.S.doc Version 5.2 Page 11 Records demonstrated that care plans were reviewed on a regular basis and this ensured that changing needs were identified and addressed. Records were in place to show that care reviews were undertaken regularly within a multi disciplinary and rehabilitation framework. This demonstrates that a person centred approach is given to each persons care by involving the significant people that support them within their health, personal and social care needs. Although both of the people spoken with confirmed that they were happy with their care plans, records were not in place to demonstrate this. Discussions took place with the registered manager regarding this. Advocacy services were available to support the people living at Cleeve Villas. Discussions with the manager confirmed that they were used to support people in responding to quality assurance questionnaires and any other areas were it was felt necessary or their support was requested. The staff encouraged and supported people living at the home to make decisions and choices regarding their daily lives. This was confirmed in discussions with the two people case tracked and was also observed on the day of this inspection visit. The risk assessments seen were detailed and instructed the staff team of the actions that were to be taken to reduce the risk identified. Risk assessments were regularly reviewed and this ensured that appropriate support could be provided. This ensured each person’s safety could be maintained without limiting his or her preferred activity or choice. This enabled each person to stay as independent as possible. Cleeve Villas DS0000061805.V362879.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): 12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person is treated as an individual and the staff support people to follow their personal interests and encourage choice and independence as much as possible. EVIDENCE: Discussions with the registered manager confirmed that additional hours are now in place to support the people living at the home with leisure and community activities. These hours are provided for three days a week and are used to provide one to one activities as well as group activities. A roster was in place that demonstrated the activities that were being undertaken and the people involved in those activities. This roster demonstrated that the activities planned were personalised to individuals and group choices and preferences. This demonstrates that the home supports people to follow their personal interests and activities. Cleeve Villas DS0000061805.V362879.R01.S.doc Version 5.2 Page 13 The activities roster corresponded with the information in the care plans and risk assessments seen regarding social, recreational, educational and occupational activities both within the home and outside in the community. The activities included one to one educational classes, mental health support groups within the community and a rehabilitation support group. As stated in the AQAA, community links were also maintained such as accessing local leisure centres, shopping centres, pubs and trips out. Comments within staff surveys indicated that, additional funds for recreational activities would enhance the recreational and leisure opportunities available to the people living at the home Plans were being made for the annual holiday. The people living at the home had chosen the holiday destination and this was confirmed by one of the people case tracked. Discussions with the two people case tracked confirmed that they were consulted regarding their preferred daily routine, including any activities they wished to undertake. Both people said that the staff were very supportive in allowing them to follow their personal interests and activities. Comments included, “its very relaxed, you can go out and go into town. I sometimes go for a walk” and “ it’s a very relaxed atmosphere, the staff are great really friendly and approachable” Information on individual’s records and from discussions with two of the people living at the home indicated that contact with family and friends was appropriate. Discussions took place with the chef and the two people case tracked about the meals provided. Meal choices were varied and records were seen to demonstrate that special diets were catered for as required. A comment from one person living at the home, regarding the meals provided was, “the food is good, there’s plenty of choice and its good quality”. Comments within some staff surveys indicated that the quality of the food provided could be improved upon. One of the people case tracked discussed how they were able to plan and prepare a meal with staff support. This person said that they didn’t have a big appetite and only liked certain foods. Therefore by supporting this person to plan and cook their own meals, the staff team encouraged and educated this person regarding the different options available that they would enjoy. Cleeve Villas DS0000061805.V362879.R01.S.doc Version 5.2 Page 14 This demonstrates that the staff team support individuals to be as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Cleeve Villas DS0000061805.V362879.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s personal and healthcare needs are supported and met. The medication practices in place ensure people are kept safe. EVIDENCE: As stated in the AQAA, records seen demonstrated that health and personal support needs were met. Health care services were accessed within the community, such as G.P, optician and hospital appointments. These were provided with staff support if required. Records were seen to show that the people living at the home were encouraged and supported to access self help groups, in order to promote their health, such as groups to quit smoking. The medication practices of the home were looked at. This included the medication records held for the two people case tracked. The records for receipt and disposal of medication was looked at and a visual check on the Cleeve Villas DS0000061805.V362879.R01.S.doc Version 5.2 Page 16 storage facilities for medication was seen. The practices in place demonstrated that the people at the home were supported to live in a safe way. Cleeve Villas DS0000061805.V362879.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. If people have concerns they know how to complain. Complaints are taken seriously and acted upon. The practices in place safeguard people from abuse. EVIDENCE: The service has received one complaint since the last inspection visit. This complaint was made by one of the people living at the home. The records demonstrated that actions had been taken to ensure a satisfactory outcome was achieved. This demonstrates that concerns are looked into and actions are taken to put things right. From discussions with the two people case tracked and within the surveys returned it was confirmed that people knew how and who to raise concerns to, and were confident that any concerns they had would be taken seriously and addressed promptly. As stated in the AQAA the records seen demonstrated that all staff had received training in Safeguarding Adults and how to deal with violence and aggression. The homes policy on Safeguarding Adults was looked at and operated to the Local Authority procedures, who are the lead investigators in Safeguarding Cleeve Villas DS0000061805.V362879.R01.S.doc Version 5.2 Page 18 Adults. This means that the correct procedures are in place for staff to follow if any suspicions or allegations of abuse are made. Staff spoken with demonstrated a good understanding of the Safeguarding policy and procedure and this means that the people living at the home can be confident that the staff know how to keep them safe. Suitable accounting procedures were in place for the monies held for the two people case tracked. This means that people’s financial welfare was protected. Cleeve Villas DS0000061805.V362879.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standards of hygiene and ongoing maintenance in place provide a safe and well-maintained home for the people that live there, which enhances their wellbeing. EVIDENCE: A partial tour of the home was undertaken. The areas seen were well maintained, clean and furnished to a satisfactory standard. Comments within surveys completed by people living at the home included, “the home is fresh and clean every day. Mopping and hovering and dusting”. As stated in the AQAA a lift has been installed since the last inspection. This demonstrates that the home ensures they improve their accessibility to benefit a wider group of people and respond to the changing needs of the people living at the home. Cleeve Villas DS0000061805.V362879.R01.S.doc Version 5.2 Page 20 Audits were in place to show the maintenance, redecoration and refurbishment of the home that was due to be undertaken within the next five months. This demonstrates that the provider and manager are proactive in ensuring that the maintenance of the home is ongoing. This means that a well-maintained environment is provided for the people that live there. Discussions with the manager confirmed that since the last inspection visit, an additional member of staff has been appointed to assist with domestic duties. It was confirmed that this has reduced care staff hours being used for domestic tasks, which had impacted on the support provided to the people living at the home. A rehabilitation room, which housed kitchen and domestic appliances, was available for use by the people living at the home. Discussions took place with one person living at the home, who confirmed this room was used and discussed how staff had supported them in cooking and doing their laundry. This demonstrates that people are supported and encouraged to be independent. There is a dedicated smoking area to the rear of the home. It was noted that this room was noisy and this was due to the air purifying system in place. One of the people case tracked commented on this and felt that the room did not provide a comfortable and relaxing environment for them to smoke in. Although it is acknowledged that smoking should not be encouraged, consideration should be given as to how a comfortable environment can be provided, within the confines of smoking legislation and health and safety regulations. Cleeve Villas DS0000061805.V362879.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): 32,34,35 AND 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The qualifications and numbers of staff on duty ensure the people living at the home are appropriately supported. The recruitment practices followed do not fully protect the people living at the home. This has the potential to put them at risk. EVIDENCE: As stated in the AQAA the home operates a key worker system. Staff spoken with had a good understanding of individuals needs. This means that the people living at the home can be confident that staff area aware of their needs and therefore will be able to support them in meeting those needs. The AQAA stated that all care staff had achieved a National Vocational Qualification (NVQ) at level 2 and the majority at level 3. Evidence was seen within the staff files looked at of NVQ qualifications. The rotas demonstrated that the skill mix and numbers of staff on duty were sufficient to support the needs of the people living at the home. This was also confirmed by the people case tracked. However there were comments made Cleeve Villas DS0000061805.V362879.R01.S.doc Version 5.2 Page 22 within staff surveys that indicated that the skill mix of staff was not always satisfactory in meeting the needs of the people using the service. The manager said that he has one supernumerary shift a week to undertake management duties. Discussions took place regarding this and whether this was sufficient to enable the manager to undertake management duties, such as formal supervision with staff. It was confirmed that staff supervision had not recently been undertaken and was out of date. This means that there is the potential for staff to not be supported appropriately, which could impact on people’s needs not being met. Comments within staff surveys confirmed that regular supervision was not taking place and that staff meetings were not held regularly. Comments within the surveys indicated that the lack of management support had the potential to impact on care practices. However the manager did confirm that the recently appointed deputy managers post should provide additional management support and enable management tasks such as formal supervision to be undertaken. The recruitment records for two members of staff were looked at and in general were satisfactory. Improvements had been made to the information requested regarding staff’s employment history. However it still did not request a full employment history. This means that any gaps in employment cannot be clearly identified and explored. This potentially could put people using the service at risk. The staff’s training records were looked at, including induction-training records. Records demonstrated that staff were trained and updated as required in all mandatory training and in training specific to the needs of the people using the service. Within the staff files seen certificates of up to date training were in place. Cleeve Villas DS0000061805.V362879.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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at the home benefit from a home that is well managed and the environment is safe for the people living there. EVIDENCE: The registered manager has the nursing and management qualifications, skills and experience required to manage the service effectively. Both staff and the two people case tracked were complimentary regarding the manager’s ability to run the home. This means that people can be confident that the home is managed appropriately. Cleeve Villas DS0000061805.V362879.R01.S.doc Version 5.2 Page 24 Records of monthly visits to the service that had been undertaken by the provider were seen. Improvements have been made to the format and information recorded at these visits. However the information provided could be more specific in detail and this was discussed with the provider. Quality assurance practices in place enabled the people living at the home an opportunity to voice their opinions of the service and ensured the registered manager and provider could monitor the support and services provided. Evidence was seen of minutes of monthly meetings that were undertaken by people living at the home and satisfaction questionnaires. A quality assurance questionnaire had been sent out to the people living at the home in August 2007. These surveys were completed by seven of the ten people sent out to. The surveys covered the homes environment and the issues of cleanliness, decoration and other environmental issues. This was done as the home was undergoing refurbishment and the manager and provider wanted to assess the effect this was having on the people living at the home. The results seen indicated that there had been little impact on the people living at the home, with a positive response recorded. This indicates that the support provided by the staff team ensured that the routines and lifestyles of the people living at the home were maintained throughout the homes refurbishment A sample of the homes policies were looked and many seen had been reviewed and updated as required. The registered manager stated that the reviewing of policies was ongoing. This demonstrates that the provider and manager endeavour to keep staff informed of current practices. This ensures the welfare rights and best interests of the people living at the home are maintained. A sample of service and maintenance certificates was seen. As recorded in the AQAA the certificates for the maintenance of equipment were up to date. This included an up to date nurse call system and gas and electrical appliance certificates. A detailed fire risk assessment was in place that had been completed in January 2008. Records of valid fire training, fire alarm tests, fire fighting equipment and fire test services were also in place. This means that the environment is safe for the people living at the home and staff and visitors, because health and safety practices are carried out. Cleeve Villas DS0000061805.V362879.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 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 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Cleeve Villas DS0000061805.V362879.R01.S.doc Version 5.2 Page 26 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. 1. Standard YA34 Regulation 19 Schedule 2 and 4 Requirement A full employment history, which includes, day/month and year of all employment start and end dates must be recorded. This will ensure any gaps in employment can be identified. A record must be made of the reasons for any gaps in employment, to demonstrate they have been explored. This is part of a requirement left at the previous inspection regarding recruitment documents that must be in place. This part of the requirement was not met within the timescale given of 30/06/07 All staff must have regularly supervision in line with the National Minimum Standard 6.4. This is a previous requirement Timescale of 31/05/07 not met. Timescale for action 01/07/08 2. YA36 18 01/09/08 Cleeve Villas DS0000061805.V362879.R01.S.doc Version 5.2 Page 27 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 YA6 Good Practice Recommendations Service user and their families should be given the opportunity to sign their care plan. This is a previous recommendation. Although it is acknowledged that smoking should not be encouraged, consideration should be given as to how a comfortable environment can be provided, within the confines of smoking legislation and health and safety regulations for the people living at the home that wish to smoke. When gaps in employment history is investigated this should be formally recorded on interview minutes. This is a previous recommendation. The Registered Person should ensure that individual staff interview records are signed and dated. This is a previous recommendation. As part of assessing the quality of care provided by the home consultation with stakeholders and service user representatives must be undertaken 2. YA24 3. YA34 4. YA34 5. YA39 Cleeve Villas DS0000061805.V362879.R01.S.doc Version 5.2 Page 28 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 Cleeve Villas DS0000061805.V362879.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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