Care Home: Denecroft

Similar services:

• Thorndene
• Insight - Eastchurch
• Southfields
• Magenta
• Seabourne House
• 33 St John`s Church Road
• Dovedale Court
• Lyncol House

What the care home does well Service user`s views are continually sought to improve the service the home provides. The manager stated she speaks with the service users on a daily basis and addresses issues as they arise. The inspector spoke to all the service users; they were happy and it was very clear the service users and staff have a good relationship. People who use the service were well dressed and each service user is treated with respect and dignity. The dining area is nicely furnished and homely and all the service users enjoyed their evening meal. The table was nicely laid the food was plentiful and appeared appetising and nourishing and there is a choice of menu, one service user had cooked shepherds pie at a cookery class and was eating the meal she had cooked. Another service user had cooked pasta and she decided she did not like what she had cooked and promptly scrapped the pasta in the bin. Staff were very anxious that the service user should have something else to eat and was offering her all different choices. The home was clean, nicely decorated and furnished. The majority of service users had some items of furniture in their bedrooms, which they have purchased. In the AQAA, to demonstrate what the home does well, the manager stated that SeeAbilities commitment to staff training and development has been recognised with the achievement of the Investor in People Award. What has improved since the last inspection? Detailed in the AQAA are some of the changes that have been made as a result of listening to people who use the service: All personal space has been decorated and refurbished, Communal areas have been modernised, activities are more person centred. In promoting the service, there is a statement in SeeAbilitys overview brochure that outlines that Denecroft promotes human and civil rights and equality. The home offers services that are sensitive to race, culture, religion, disability and sexual orientation. This is to ensure the home is able to meet the needs of the individual service user. What the care home could do better: The executive management have identified that they have some shortfalls and are addressing these areas, particuarly regarding staff vacancies and have recently recruited a new manager. Management have taken a view that they want to recruit permanent quality staff to enable the home to achieve stability for the service users living in the home. CARE HOME ADULTS 18-65 Denecroft Denecroft 1 Denmark Road Guildford Surrey GU1 4DA Lead Inspector Vera Bulbeck Unannounced Inspection 22nd January 2008 10:55 Denecroft DS0000013625.V355524.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 Denecroft DS0000013625.V355524.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. Denecroft DS0000013625.V355524.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Denecroft Address Denecroft 1 Denmark Road Guildford Surrey GU1 4DA 01483 301315 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) s.lock@seeability.org SeeAbility Mrs Sara Louise Lock Care Home 6 Category(ies) of Learning disability (0), Sensory impairment (0) registration, with number of places Denecroft DS0000013625.V355524.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 - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability - (LD) 2. Sensory Impairment - (SI) The maximum number of service users to be accommodated is 6. Date of last inspection 7th August 2006 Brief Description of the Service: Denecroft is a large detached property situated in a pleasant residential area of Guildford. It is close to local facilities and amenities. The service provides personal care and accommodation for up to six adults with learning disabilities, visual impairment and challenging behaviour. There are five female service users and one male. All service users have single rooms, and some have ensuite facilities. The accommodation is on two floors and there is no lift to the upper floor, however, current service users do not require this at present. There is a terraced area with a patio and vegetable garden, and car parking to the rear of the property. Car parking spaces are limited at the back of the home for any visitors and there is a constant movement of cars in and out of the car park, which means someone, is constantly moving their car. There is parking outside the home on meters for a limited period of two hours and there is parking in the car park adjacent to the council offices. The fees are ranged from £1,200.16 to £1,431.96 per week and do not include personal items, hairdressing and some travel costs. Denecroft DS0000013625.V355524.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. This unannounced site visit formed part of the key inspection process and took place over seven hours thirty minutes commencing at 11.00am and ending at 18.30pm. Mrs V Bulbeck, Regulation Inspector carried out the visit. A full tour of the premises was undertaken. Two care plans were sampled and the care observed for the two individuals. A number of records were sampled. The inspector spoke with all the service users living in the home. The inspector was also able to speak to all the staff on duty. Surveys have been sent to relatives/friends, care staff, General Practitioners and Social Services Care Managers. The Inspector would like to thank the registered manager Ms Sara Lock who was on annual leave but choose to come in for the inspection process. There were six service users living in the home on the day of the site visit and there was one service user living in the home on a trial basis. The inspector would like to thank the service users and staff for their cooperation and hospitality during the inspection. What the service does well: Service user’s views are continually sought to improve the service the home provides. The manager stated she speaks with the service users on a daily basis and addresses issues as they arise. The inspector spoke to all the service users; they were happy and it was very clear the service users and staff have a good relationship. People who use the service were well dressed and each service user is treated with respect and dignity. The dining area is nicely furnished and homely and all the service users enjoyed their evening meal. The table was nicely laid the food was plentiful and appeared appetising and nourishing and there is a choice of menu, one service user had cooked shepherds pie at a cookery class and was eating the meal she had cooked. Another service user had cooked pasta and she decided she did not like what she had cooked and promptly scrapped the pasta in the bin. Staff were very anxious that the service user should have something else to eat and was offering her all different choices. Denecroft DS0000013625.V355524.R01.S.doc Version 5.2 Page 6 The home was clean, nicely decorated and furnished. The majority of service users had some items of furniture in their bedrooms, which they have purchased. In the AQAA, to demonstrate what the home does well, the manager stated that SeeAbilities commitment to staff training and development has been recognised with the achievement of the Investor in People Award. 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. Denecroft DS0000013625.V355524.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 Denecroft DS0000013625.V355524.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New admissions to the home are only admitted following a needs assessment to ensure that the home can meet the service users’ identified needs. The home does not offer intermediate care. EVIDENCE: The majority of service users living in the home have lived in the home for some time. However, one service user has recently been admitted to the home on an emergency placement and the manager explained that a pre needs assessment had not been undertaken. However, a number of assessments have been undertaken since the service user moved into the home. The inspector advised the manager that any admissions to the home should have a pre assessment to ensure the home can meet the service users needs prior to admission. The manager explained that an assessment tool is normally used and full details of any potentially new persons would be undertaken before the person enters the home. The manger explained the admission procedure and criteria to reflect the principles of admission and assessment appropriate to the home. This should be reflected in the homes statement of purpose. The statement of purpose was not seen at this site visit. Denecroft DS0000013625.V355524.R01.S.doc Version 5.2 Page 9 The home does not offer intermediate care. Denecroft DS0000013625.V355524.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 service users’ health, personal and social care needs are set out in an individual plan of care, in accordance with the homes philosophy. People who use the service are able to make decisions on their lifestyles and to be more independent where possible with staff support. EVIDENCE: Two care plans were sampled and the manager informed the inspector that the care plans are in the process of being changed to be more person centred. The care plans have all the relevant information including risk assessments and health care needs. Each service user has a separate book, which records the daily progress of each individual service user, the records are well documented and provides information relevant to meet the needs of people who use the service. The care plans are kept in the manager’s office, and staff has access to them. It was noted in the service user’s notes, health, personal and social care needs had been identified and assessed and again these are in the process of being changed. This includes optical, dental and health professional involvement, as Denecroft DS0000013625.V355524.R01.S.doc Version 5.2 Page 11 well as the G.P. The service users are involved with their care plan with staff support. Staff stated that service users are supported to make decisions affecting their lives in a number of ways. There are regular meetings and service users are able to choose and be involved with decision-making and have more choice over their individual well being, holidays, menu planning and outings are mainly discussed. Observation by the inspector, staff are respectful to the service users. It was also noted that some individuals and staff have a good rapport. Denecroft DS0000013625.V355524.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, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users have some opportunities for personal development and to take part in appropriate activities within the home and in the local community. They are supported to maintain and develop appropriate personal and family relationships. EVIDENCE: All the service users are able to enjoy holidays and the home is in the process of booking a holiday for 2008. Unfortunately the people who use the service did not have a holiday during 2007 except for one service user was able to visit her sister for a holiday. The manager informed the inspector that all the service users would have a weekend away before the end of March. Service users enjoy going shopping and table top activities. Some are able to use the local library, others enjoy making jewellery and two service users go line dancing. A number of service users attend various colleges for cookery, on the day of the site visit two service users had been to their class and each Denecroft DS0000013625.V355524.R01.S.doc Version 5.2 Page 13 had cooked their own evening meal. One person had cooked shepherds pie and was very proud of her achievement and was happy to show the inspector what she had made. The other service user had cooked pasta and she did not enjoy her meal at all, in fact she scrapped the pasta into the bin. Staff asked her what she would like to eat; various options were put to her, before she made her decision. Other classes attended at the colleges are art therapy and a sensory class. Another service user attends the Millennium centre for life skills, and on a weekly basis the Shay Kit n all Bang play music and all the service users enjoy the morning. Two service users are able to participate with staff support laundry duties and one service user likes to change her bed linen when necessary with support by a member of staff. A number of service users have contact with their family. The staff stated that the families are very interested in the care of their relatives. The inspector had a limited conversation with the service users, however it was very clear that staff have a very good understanding of the needs of service users and was able to discuss issues and respond by a number of methods. It is recommended that any person without a relative or friend would benefit from an advocate involvement to ensure the service users have the support they need. The inspector was able to observe the service users living in the home. The mealtime was pleasant the service users clearly enjoyed their meal. The food was nutritional in content and advice is sought when required from a nutritionist. Mealtime was a very social occasion, with staff sitting eating as well. Denecroft DS0000013625.V355524.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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance was documented and observed to be provided, where needed, in a respectful and sensitive manner. Policies and practices are in place for the administration and management of medications and was being administered by competent trained staff. EVIDENCE: The inspector was informed by staff that the service users are able to choose when to go to bed and when to get up and are supported to choose their own clothes, hairstyles and other aspects of personal grooming. Service users were unable to confirm however the inspector observed the interaction between service users and staff, which is very good. There are regular visits to the local G.P and individuals have an annual health check. The medical team as well as other professional health care people, these include the dentist, optician, chiropodist and Physiotherapist when required. Denecroft DS0000013625.V355524.R01.S.doc Version 5.2 Page 15 A number of risk assessments were seen on the two care plans sampled. The confidential notes currently in the care notes are stored appropriately in a locked facility; care plans are used as a working tool for all staff. The system for medication administration was seen and was undertaken by staff that had received medication training. The Medication Administration Record (MAR) sheets were seen for the two individuals who were case tracked and it was noted that the recording records had no gaps and are kept up to date. There are no people who use the service who are able to self medicate. Management of the home must ensure appropriate risk assessments are in place to ensure medication is taken as directed. The doctor can only change the dosage prescribed and this must be clearly shown on the MARR sheets. The pharmacist must undertake any changes to the label on the medication prescribed as discussed at the time of the site visit. Denecroft DS0000013625.V355524.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All staff have received training in protecting vulnerable people and are aware of the procedures and practices, to ensure that service users are safeguarded, as far as reasonably possible, from harm or abuse. EVIDENCE: The home has received one complaint and records indicated the complaint was dealt with appropriately. The Commission for Social Care Inspection (CSCI) has not received any complaints. A referral was made to the safeguarding team and two members of staff were referred to the POVA list as a result of the investigation. However, the bureau that undertakes referrals to be added to the POVA list stated the names would not be included on the list. We the Commission observed all the service users on the day of the inspection and all were spoken to. Staff stated that service users would be able to indicate if they were unhappy about something. The complaints procedure needs to be produced in a format the service user would be able to understand and this may be for each individual. The manager stated that relatives have been provided with a copy of the complaints procedure and a copy of the National Minimum Standards for Younger Adults during a coffee afternoon in July 2007. There is also a whistle blowing policy in practice and all staff spoken to confirmed they were aware and would not hesitate to report to their peers if they witnessed any form of abuse. All staff has received training on the protection of vulnerable adults and training certificates were on each member of staffs file. It was also noted that Denecroft DS0000013625.V355524.R01.S.doc Version 5.2 Page 17 the home had a copy of surrey multi agency procedures. The notice board in the hallway has information regarding complaints, concerns and compliments. Denecroft DS0000013625.V355524.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements to the home are ongoing to ensure service users live in a safe well maintained home. The premises were homely and nicely presented. All areas in the home were clean and hygienic. EVIDENCE: The home was clean and bedrooms were personalised with service users belongings. The majority of the service users keep their bedrooms clean and tidy with support from staff. A key worker system is in operation, which works well for the service users. Each bedroom has a lockable cabinet and service users medication is stored in these cabinets. The staff holds the keys for the lockable cabinet on the bedroom wall and the bedroom doors. Information needs to be recorded in service users care plans regarding the reasons for people who use the service not holding a key to their bedroom door. Denecroft DS0000013625.V355524.R01.S.doc Version 5.2 Page 19 The notice board in the hallway has information regarding complaints, concerns and compliments. There are also photographs of the staff team and the staff on duty during each day and a photograph of each service user displayed on the board. A computer sits on a small table in the dining area and one service user is able to use it. The manager stated the kitchen is being replaced before the end of March, it was noted there are some areas on the work surfaces that are badly stained. Denecroft DS0000013625.V355524.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): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and staff training are maintained to enable staff to provide the care and attention to people who use the service need. This ensures the service users are treated with respect and dignity at all times and their individual needs are being met. EVIDENCE: The staff rota evidenced that staff are provided in sufficient numbers to meet the needs of the service users at the home. The morning (7am – 3pm) shift is covered by two care workers, two care workers cover the afternoon/evening shift (6pm – 10pm) and the night staff consists of one sleeping in care worker and a person on call if needed. Of the six permanent care staff, two hold a National Vocational Qualification (NVQ) level 3 and above in care, and one staff with NVQ Level 2 and a another member of staff currently undertaking NVQ level 2. During this visit the files of two members of staff were sampled one being a newly recruited member of staff. The staff files checked were seen to contain proof of identity, two references, a completed application form and enhanced Denecroft DS0000013625.V355524.R01.S.doc Version 5.2 Page 21 Criminal Record Bureau (CRB) and Protection of Vulnerable Adult (POVA) list checks had been obtained. The home also verifies applicants’ reasons for leaving previous employment with vulnerable adults; ensure they obtain a full employment history and a written explanation of any gaps in employment. All staff surveyed confirmed they had been supplied with a copy of the General Social Care Council (GSCC) code of conduct and practice. Staff induction is in line with the new, mandatory Skills for Care common induction standards and we the Commission was advised that staff are supervised until they have completed their induction. A number of staff have undertaken equality and diversity training, staff are booked on additional training and updates as the courses become available. In the AQAA, to demonstrate what the home does well, the manager stated that SeeAbilities commitment to staff training and development has been recognised with the achievement of the Investor in People Award. One member of staff commented that she was ‘very happy with the level of training’ provided by the home. Denecroft DS0000013625.V355524.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, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from the management approach at the home providing an open, positive and inclusive atmosphere. The home has a quality assurance and monitoring system in place that is based on seeking the views of the service users. Policies and procedures are in place to ensure, so far as is reasonably practicable, the health, safety and welfare of service users and staff. EVIDENCE: The manager has been in post for a few months and is in the process of updating several areas in the home and is committed to managing a good service. In the AQAA, to demonstrate what the home does well, the manager stated that the manager has the Registered Managers Award (RMA) and NVQ 4 in Care, also D32/D33 Assessor DMS, C & G 325.3(Distinction) and NNEB. The Denecroft DS0000013625.V355524.R01.S.doc Version 5.2 Page 23 manager also has experience of supporting people with learning disabilities and additional needs for over 20 years. Service users’ views are sought on a regular basis and monthly visits by a representative of the responsible individual take place as required. There were three regulation 26 visits reports missing, these visits need to be undertaken on a regular monthly basis. The Inspector was informed that the organisation carry out a yearly survey, which seeks the views of service users, family, friends and other stakeholders in the community (i.e. district nurses etc.) The report of 2006 survey was seen at this inspection. The manager stated another survey is to be undertaken very shortly. All necessary health and safety checks are carried out by the staff at the home with documentary evidence of inspected routine fire practices the fire alarm system is tested on a weekly basis and evacuations are well documented, fire equipment checks are recorded monthly. The inspector advised the manager to seek the guidance of the fire safety officer regarding an emergency fire safety contingency plan. Daily checks of the fridge and freezer temperatures and the recording of the temperature of cooked meat were seen. A number of up to date maintenance certificates were seen. The records sampled were up to date and well maintained. It was also noted that any accidents and incidents in the home are recorded on the old type of system for recording accidents and incidents. Staff need to ensure they are aware of the data protection procedures as required by the HSE and record on the correct format. A relatives who returned a comment card stated that they were always kept up to date with important issues affecting their relatives and that they felt the home meets the different needs of the service users (two answered ‘always’ and two answered ‘usually’ All interactions observed between the staff and service users were inclusive, caring and respectful. Denecroft DS0000013625.V355524.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 X 2 X 3 3 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 3 35 3 36 X 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 4 13 3 14 X 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X X X 3 X X 3 X Denecroft DS0000013625.V355524.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard YA6 YA6 YA22 YA34 YA42 YA42 Good Practice Recommendations Care plans need to be more person centred Service users who are unable to hold keys for their bedroom should be documented in their plan of care the reasons for not holding a key. Complaints procedure needs to be in a format to enable service users to understand. All CRB need to be up dated approximately every three years. The accident book needs to comply with the data protection procedures. Regulation 26 visits need to be undertaken on a monthly basis. Denecroft DS0000013625.V355524.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Kent ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email:inspection.southeast@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 Denecroft DS0000013625.V355524.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!