Care Home: Companion in Care

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What the care home does well The home was generally well maintained, both internally and externally, and all service users have their own bedrooms, which they have been able to personalise to their individual tastes. Service users spoken to expressed satisfaction with the home, one commented "I tell you one thing, I have never been as happy as I am here." Service users have a large measure of control over their daily lives, one informed the inspector that "I can come and go as I like." There was evidence that the home aims to promote service users independence, for example through cooking and shopping, and that the home seeks to meet needs around equality and diversity issues, such as religion and culture. What has improved since the last inspection? There have been improvements to the home since the previous inspection, and the overall number of requirements set has fallen. The staff team have received appropriate training, and over 50% of care staff now have a relevant care qualification. Risk assessments have been updated, and now include guidance on managing any challenging behaviours service users present. The broken wall in the front garden has been removed. CARE HOME ADULTS 18-65 Companion in Care 24 Borthwick Road Leyton London E15 1UD Lead Inspector Rob Cole Unannounced Inspection 8th September 2008 10:00 Companion in Care DS0000043228.V369419.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 Companion in Care DS0000043228.V369419.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. Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Companion in Care Address 24 Borthwick Road Leyton London E15 1UD 020 8519 4135 020 8809 7044 companionincare@hotmail.com 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) Companion In Care Ltd Mrs Kehinde Ollifunso Ajumobi Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th September 2006 Brief Description of the Service: Borthwick Road is a three bed-roomed house registered to provide care to adults of either gender with a mental disorder. The home was first registered in February 2004. The home is situated in a residential area of Leyton, in the London Borough of Waltham Forest, and is close to shops and other local amenities, and transport networks. The home is indistinguishable from other homes in the area. The home is privately run. Companion in Care DS0000043228.V369419.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 two stars. This means the people who use this service experience good quality outcomes. This inspection took place on the 8/9/08 and was unannounced. The inspector had the opportunity of speaking with service users, and staff from the home. In addition to this the inspector was also able to observe staff interaction with service users throughout the course of the inspection. The inspection included an examination of records and other documents, along with a tour of the premises. Prior to the inspection, the CSCI issued surveys to service users and social and health care professionals, six of these were completed and returned. The CSCI requested that the home complete and Annual Quality Assurance Assessment (AQAA), which was completed and returned to the CVSC within agreed timescales. All of this has helped to form judgments made within this report, and contributed to the overall inspection process. What the service does well: What has improved since the last inspection? What they could do better: Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 6 Despite these improvements, there are still some issues that must be addressed. The home must ensure that fire alarms are serviced annually, and comprehensive records must be kept of any medications returned to the pharmacist. 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. Companion in Care DS0000043228.V369419.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 Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that prospective service users are provided with sufficient information about the home to make an informed choice as to move in or not. This information is provided through written documentation and the opportunity of visiting the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. Both documents are written in plain English, and are dated and subject to regular review. The Statement of Purpose includes details of the organisational structure and of the services and facilities provided by the home. The Statement includes the homes philosophy of care, which is “To provide a safe environment to all users of our service in which they will be valued, empowered and enabled to explore all areas of their lives and to develop lost and new skills.” The Service User Guide includes details of the homes physical environment and the complaints procedure, and is in line with National Minimum Standards. All service users are provided with their own copy of the Guide. Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 9 Service users are given a contract/statement of terms and conditions. These have been signed by service users and the homes manager. Contracts include details of fees payable, and the services and facilities provided by the home. Although there have been no new admissions to the home since the last inspection, the home has an admissions procedure, which covers planned and emergency admissions. The procedure states that service users will be able to visit the home before making any decision as to move in or not. Service users spoken to confirmed that they were indeed given this opportunity. Companion in Care DS0000043228.V369419.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): 6,7,8,9 and 10. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that service users have a large measure of control over their daily lives, and are given the opportunity of been involved in the day to ay running of the home. EVIDENCE: Individual care plans are in place for all service users. These have been drawn up with the involvement of the service user, their keyworker and the homes manager, and are subject to regular review. Care plans are completed on a pro forma, which has sections for goals to be achieved, action plans and progress and outcomes. Care plans are clear and comprehensive, and of a satisfactory standard, covering subjects such as mental and physical health, medication and activities, along with equality and diversity issues including culture and religion. All service users are on the Care Programme Approach, and these Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 11 meetings feed into the care planning process, as do annual meetings held in conjunction with the service users placing authority. Risk assessments are in place for all service users, and as with care plans these are of a satisfactory standard and subject to regular review. Assessments identify any risks, and include strategies to manage and reduce these risks, for instance around self neglect and violence and aggression. Assessments make clear that service users are able to take reasonable risks, for example accessing the community without the support of staff, which helps to promote independence and dignity. There was evidence that service users have a large measure of control over their daily lives. Surveys completed by service users at the request of the CSCI indicated that service users are able to make choices over their lives on a daily basis, and service users were observed to be able to get up at a time of their choosing, and to come and go from the house as they chose. One service user informed the inspector “I can get up and get a cup of tea and watch TV anytime I want.” Service users are involved in the day to day running of the home. Service users are involved in the daily routines, for example keeping bedrooms tidy and preparing meals. Regular service user meetings are held, which provides an opportunity for service users to discuss any issues of interest or concern to them. Minutes of service user meetings evidenced discussions around menus and activities, and there was evidence that decisions taken a meetings are acted upon. For instance at a recent meeting service users stated they would like the home to arrange a trip to London Zoo, and this was subsequently organized. Staff informed the inspector that it is planned that both communal and private areas within the home are to be decorated before the end of this year, and that service users will be given the opportunity of choosing this new décor. The home has a confidentiality policy in place. This makes clear under what circumstances a confidence may be broken in the health, safety and welfare interests of service users and others. Staff spoken to demonstrated a good understanding of the issues involved around confidentiality. Confidential records were stored securely, and staff and service users can access their records as appropriate. Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that service users are supported to live valued and fulfilling lives. Service users have routine access to the community, and food provided is of a good standard. EVIDENCE: No service users are currently involved in any formal educational or employment opportunities. Two service users attend a local day service, where they have access to various leisure activities such as playing pool, and the chance to help develop skills, for example IT skills. The day service also presents the opportunity of developing and maintaining friendships. Service users have regular access to the local community, and all are able to come and go from the home as they choose. All service users have been provided wit keys to the front door of the home and their bedrooms. On the Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 13 day of inspection one service user was observed to go out for approximately two hours, they informed the inspector that they had been to see friends at a local café, and to the shops. Service users access other local facilities, including parks, hairdressers and banks. Service users access public transport, including buses and trains. One service user goes to church every week, thus helping to meet their needs around equality and diversity issues. Generally, service users arrange their own social and leisure activities, service users spoken to informed the inspector that they were happy with this arrangement, which gave them choice and control over what they do. The home does arrange some activities, such as meals out and trips to the cinema, and occasional day trips, as mentioned the home recently arranged a trip to London Zoo. In house service users have access to a variety of social and leisure activities, including television, music, DVD’s and board games. The home arranges occasional parties, for example to celebrate birthdays. Since the previous inspection one service user visited Dublin to see members of their family. The inspector was impressed with the amount of work the home put in to facilitate this trip, and the service user informed the inspector that they very much enjoyed this opportunity, and were hoping to go again in the near future. The home has also got a passport for another service user, to enable them to visit family in the Caribbean if they wish to. Service users are able to maintain contact with family and friends by telephone, and are able to receive visitors in to the home. Service users are able to see visitors in private if they so wish. Records are maintained of menus, these indicated that service users are offered a varied, nutritious and balanced diet. The home has a weekly meeting to plan the menu for the week ahead, and service users are involved in food preparation, including buying food. There was evidence that service users have a large degree of control over what they have for meals, records indicated that service users often have different meals to each other. The kitchen was clean and tidy, and food was stored appropriately. To help meet needs around equality and diversity issues, the home has arranged various themed food days, planned with the service users, to provide food from particular cultural backgrounds, including Irish and Caribbean food. Records are maintained of fridge and freezer temperatures. Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 14 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. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that the home is able to meet the health and personal care needs of service users. Service users are supported to manage their own personal care, and the home ensures service users have access to appropriate health care professionals. EVIDENCE: All service users manage their own personal care, although staff will encourage and prompt service users with their personal care as appropriate. Service users choose their own clothes to buy and wear, and all were appropriately dressed on the day of inspection. The home has sought the wishes of service users in the event of their death, and these views have been recorded as part of their care plan. All service users are registered with a GP. Records are maintained of medical appointments, including details of any follow up action necessary. Records indicate that service users have access to health care professionals as Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 15 appropriate, including dentists, chiropodists and CPN’s. There was evidence that the home is proactive in supporting service users with their health, for instance one service user is due to have an operation this month, and the home has worked closely with them and health care professionals in preparation for this operation. The service user commented “I’m going for an operation on Friday, God bless them, I can’t wait to walk properly again.” Medication in the home is stored in a locked cabinet within the office. All staff receive training before they are able to administer medications, and the home has a medications policy in place. No service users currently self medicate or are on any controlled drugs. Records are maintained of medications entering the home. The home maintains a record of any medications that are returned to the pharmacist, i.e. a record of the type, strength, form and quantity of the medication, along with the date of its return. The home does not however record who this medication belonged to. In order to ensure that the home has clear records of any medications, including those that are returned to the pharmacist, it is required that the home records whose medications are been returned. Medication Administration Record charts are maintained. Those checked by the inspector were accurate and up to date. Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 16 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. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that the home has taken reasonable steps to help ensure that service users are safeguarded from the risk of abuse. Appropriate policies and procedures are in place, and staff demonstrated a good understanding of their roles and responsibility with regard to adult protection issues. EVIDENCE: The home has a complaints procedure in place, all service users are given their own copy of this included within the Service User Guide. Surveys completed by service users indicated that they have a good understanding of whom they can complain to if they so wish. The procedure included timescales for responding to any complaints, and contact details of the CSCI. The home also has a complaints log, which indicated that complaints are investigated and recorded as appropriate. Concerns, comments and complaints is a standing agenda item on residents meetings, giving them the opportunity to raise any issues of concern they have. The home has a copy of the Local Authorities adult protection procedure, and also its own policy on safeguarding adults. Staff spoken to demonstrated a good understanding of their roles and responsibilities with regard to adult protection. Records evidenced that all care staff in the home have undertaken Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 17 training in adult protection issues, and the home has therefore met the requirement set at the previous inspection. All service users have their own bank accounts, which only they have access to. Two service users manage their own finances, but the home holds money on behalf of one service user. The service user informed the inspector that they were very happy with this arrangement, and it helped them to budget appropriately. Their money is held in a locked cabinet, and records are maintained. The service user and the staff member involved always sign when the service user receives any money. Records checked by the inspector were accurate and up to date. Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that the home is suitable to meet its stated purpose in relation to its physical environment. The home was generally well maintained, and service users have access to adequate private and communal space. EVIDENCE: The home is situated in a residential area of Leyton, in the London Borough of Waltham Forest. The home is in keeping with other homes in the area, and is close to shops, transport links and other local amenities. The home was generally well maintained, both internally and externally. All service users have their own bedrooms, these meet National Minimum Standards on size requirements, and have been decorated to service users personal tastes, for example with posters and religious iconography, thus Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 19 helping to meet needs around equality and diversity issues. Bedrooms had appropriate furniture, including table, chair, chest of draws and wardrobes; and bedding, carpet and curtains were well maintained and domestic in character. All bedrooms have hand basins fitted. Service users have been able to bring their own possessions with them to the home, such as televisions and music systems. Bedrooms have adequate natural light and ventilation, and all are centrally heated. Communal space consists of a kitchen/dining room, sitting room and a garden. Furniture and fittings around the home were generally well maintained and domestic in character. Service users were free to move around communal areas as they wished. The home has one bathroom/toilet, one shower room and one toilet on its own, the inspector believes this to be adequate to meet service users needs. Bathrooms were clean, tidy and free from offensive odour, and all had working locks fitted, with an emergency override device. Appropriate measures are in place to help control the spread of infection, for example hand washing facilities throughout the home, and protective clothing is provided for staff. Laundry facilities are appropriate in scale to the home, and COSHH products are stored securely. At the previous inspection it was found that the wall at the edge of the front garden had been knocked down, and was a pile of rubble, this has now been addressed. However, in the rear garden there was a pile of bricks, breezeblocks and other building materials. Staff informed the inspector that they had been their since they had worked in the home, a period of approximately one year. As these are in a communal area that service users have access to, it is required that they are removed. Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 20 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): 31,32,33,34,35 and 36. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that the home is staffed in sufficient numbers to meet the needs of service users, and that staff have a good understanding of their roles and responsibilities. EVIDENCE: The home provides 24-hour support, including an emergency on-call procedure. There was a staffing rota on display, and this accurately reflected the actual staffing situation on the day of inspection. Most of the time the home operates with one care staff on duty, and the manager generally works in addition to this. As all three of the current service users are largely independent in areas such as personal care and accessing the community, the inspector is satisfied that staffing levels are adequate. Staff demonstrated a good understanding of the collective and individual needs of service users, and were observed to interact with them in a friendly and respectful manner. Service users expressed satisfaction with the staff through the surveys they completed, and during the course of the inspection one Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 21 commented of the staff “They are good people here.” Examples of positive staff interactions with service users were witnessed throughout the course of the inspection, for example with gentle encouragement to clean a bedroom. One service user said of their keyworker “My keyworker listens to me, they say if you want to buy something but it, it’s your money.” The AQAA supplied by the home indicates that the home has appropriate employment related policies and procedures in place, for example on recruitment and selection and equal opportunities. Staff employment records were tested as pat of the last key inspection of the service, and will be tested again at the next key inspection. All staff undertake a structured induction programme on commencing work at the home, this includes shadowing more experienced members of the staff team in their duties. Two of the three care staff currently employed at the home have successfully achieved and NVQ Level 2 in Care or equivalent qualification, over the 50 level set by the NMS. Staff have access to training, and recent training has included fire safety, infection control, person centred care and care planning. Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41, 42 and 43. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that this is a generally well managed home, with appropriate quality assurance systems in place. EVIDENCE: The home’s manager has ten years experience of working with adults with mental health issues, including seven years in a managerial capacity. They have an NVQ Level 4 in Care. Staff and service users informed the inspector that they found the manager to be approachable and accessible. Care plan reviews and service user meetings contribute to the quality assurance process within the home. Copies of previous inspection reports were Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 23 available to view in the home. The home issues questionnaires to service users to gain their feedback on the running of the home, completed questionnaires viewed by the inspector contained generally positive feedback, with one service user commenting “The services provided are fantastic.” The AQAA supplied by the home indicates that the home has all necessary policies and procedures in place in line with National Minimum Standards, those checked by the inspector, including complaints and admissions, were of a satisfactory standard. Record keeping within the home was of a generally good standard, and confidential records are stored securely. Staff and service users have access to their own records. Staff undertake regular health and safety training, for example on infection control and fire safety. Fire extinguishers were situated around the home, these were last serviced in June 2008. Regular fire drills are held, and the home tests fire alarms on a weekly basis. However, the fire alarms were last serviced on the 23/6/07, and it is required that the fire alarms are serviced at least once every twelve months. The home had in date safety certificates for gas safety, PAT testing and electrical appliances. Fridge/freezer and hot water temperatures are routinely checked. On the day of inspection, the homes employers liability insurance cover certificate indicated that the period of insurance had expired on the 31/08/08, and that the home was therefore operating without appropriate insurance. This was brought to the attention of the staff on duty. Subsequent to the site visit, the home was able to evidence that it now has appropriate insurance cover in place. Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 24 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 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 3 3 3 2 3 Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 25 Yes. 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 YA42 Regulation 13 and 23 Requirement The registered person must ensure that the homes fire alarms are serviced at least once every twelve months. (Timescale 30/11/07 not met) The registered person must ensure that the home maintains clear and comprehensive records of any medications that are returned to the pharmacist, including details of whom the medication belonged to. The registered person must ensure that all building materials are removed from the homes rear garden. Timescale for action 31/10/08 2. YA20 13 30/09/08 3. YA24 23 31/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Companion in Care DS0000043228.V369419.R01.S.doc Version 5.2 Page 27 - 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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