Care Home: Desboro House

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What the care home does well The care and general running of this home is led by the service users who live there, with very good support from a strong staff team, and an effective registered manager. There is a welcoming and homely atmosphere at the house and the environment is very comfortably decorated and furnished. There is an excellent rapport between service users and staff, and service users are able to take control of their own lives. Service users said that some of best things about living at the home are the chance to be more independent, having a good choice of leisure activities and plenty to do, and being listened to and taken seriously. What has improved since the last inspection? Since the last inspection visit there have been many improvements to the environment such as general redecoration and new carpets fitted in service users bedrooms; new security lights fitted in the grounds of the house; all radiators have been covered; the kitchen has been refurbished, and the garage has been converted in to an extra room, which is used as a dinning room. This was carried out following a suggestion from the service users. Service users and staff also said that care plans are now typed, which makes them easier to read and neater. What the care home could do better: No requirements or recommendations were made at this inspection and service users continue to receive a very good service. CARE HOME ADULTS 18-65 Desboro House Main Road Toynton All Saints Lincs PE23 5AE Lead Inspector Wendy Taylor Key Unannounced Inspection 07 February 2007 09:30 Desboro House DS0000002351.V323320.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 Desboro House DS0000002351.V323320.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. Desboro House DS0000002351.V323320.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Desboro House Address Main Road Toynton All Saints Lincs PE23 5AE 01790 753049 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) simon.brown@linkage.org.uk Linkage Community Trust Mr Simon Brown Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Desboro House DS0000002351.V323320.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd October 2005 Brief Description of the Service: Desboro House is a care home operated by a voluntary organisation called Linkage Community Trust Care Services. The house is a two storey detached property situated in the small village of Toynton-all-Saints, which is approximately a mile and a half from the market town of Spilsby. The home stands in its own spacious grounds and gardens. Access to work, shopping and recreational facilities is via public transport or the homes minibus, which is also shared with another home in the group located nearby. The home is registered to provide personal care for up to eight residents with a learning disability. All bedrooms are for single occupancy. The home is part of Linkage Trusts long-stay project and also operates a day centre facility at Scremby Grange approximately five and a half miles from Toynton. The residents are able to attend this facility and as part of their personal development, are also involved in community work experience projects. A number of residents are employed part-time and receive therapeutic earnings. The currently weekly fees are £499:70 to £529:00 Desboro House DS0000002351.V323320.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was carried out during February 2007 and the visit to the house took place over approximately 4½ hours on one day. Service users led the visit, showing the inspector around the home, discussing their care plans and files and talking about their experiences of living at the home. The registered manager helped the inspector to access staff and general house records. The registered manager and staff also spoke to the inspector about their experiences of working at the house and how they help the service users to live fulfilling lives and stay safe. The care and support received by two service users was followed in detail and other service users were able to be involved in the inspection by filling out surveys or talking to the inspector during the visit. Service users made comments such as ‘I love it here’, ‘very happy living here’ and ‘staff are great’. Other comments made by service users and staff are contained in the main body of the report. What the service does well: What has improved since the last inspection? Since the last inspection visit there have been many improvements to the environment such as general redecoration and new carpets fitted in service users bedrooms; new security lights fitted in the grounds of the house; all radiators have been covered; the kitchen has been refurbished, and the garage has been converted in to an extra room, which is used as a dinning room. This was carried out following a suggestion from the service users. Service users and staff also said that care plans are now typed, which makes them easier to read and neater. Desboro House DS0000002351.V323320.R01.S.doc Version 5.2 Page 6 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. Desboro House DS0000002351.V323320.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 Desboro House DS0000002351.V323320.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, 4, 5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are given detailed and accessible information, and appropriate support to enable them to make clear choices about where they want to live. They are involved in a comprehensive assessment process, which assures them that there needs will be met. EVIDENCE: The statement of purpose and service user guide are available to service users in written, sign language and DVD formats. Individual contracts are also in place and information about them is contained in the service user guide DVD. The registered manager said that staff spend time explaining the contract to the service user. The admissions policy is also available on DVD so that services users have full access to it. Surveys received prior to the visit show that service users had a choice of where to live and one person said that they ‘like it ever so much and had to wait for a vacancy’. During the visit a service user said that they were given lots of information about the home before they moved in and they confirmed that they had seen the DVD’s. They said that this helped them to choose to live at the home, as well as having the opportunity to look around. They also said that staff helped them to understand how much they pay to live at the home. Desboro House DS0000002351.V323320.R01.S.doc Version 5.2 Page 9 Each service user has an initial assessment of need and a needs profile, which directs the reader to care plans and risk assessments. The service user signs the assessments, and a service user confirmed that they were fully involved with their assessment, and their relatives were too. Desboro House DS0000002351.V323320.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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are fully involved in planning and reviewing their own care. They are able to control what happens in their daily lives and be fully involved in the day-to-day running of the home. EVIDENCE: Care plans are available for each service user. They cover areas such as daily needs, cooking, personal hygiene, road safety and behaviour management. Opportunities to make choices and be independent are very clearly recorded in the care plans, and they also clearly refer to privacy, dignity and respect. Service users sign the plans to indicate their involvement and agreement with them, and they confirmed during discussion that they take part in their development. Risk assessments are in place, which cover areas such as road safety, fire safety, healthy eating and sunburn. The risk assessments cross reference clearly with care plans so that information is not missed. Desboro House DS0000002351.V323320.R01.S.doc Version 5.2 Page 11 There is evidence in records and from discussion with service users that the plans are reviewed on a monthly basis with the service user; and there are records of monthly audits of the plans by the keyworkers. Service users said that they know what is in their files and guided the inspector through them. They said that they also have person centred plans, which say what their aspirations are for the future. They said that they are involved in cooking, cleaning, shopping and decorating; and they are able to say how they want things done. During the visit service users were undertaking household tasks and directing staff as to what they wanted to do. There was an excellent rapport between service users and staff Surveys received prior to the visit show that service users can always make decisions about what to do, and one person said that they were ‘pleased’ with what they do. Pre inspection information shows that there are policies available for risk assessment, privacy, dignity and choice. Desboro House DS0000002351.V323320.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, 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users enjoy a comprehensive range of social and leisure activities of their choice and they are supported to develop their skills of independence to whatever level they wish, both at home and in the wider community settings. EVIDENCE: Individual timetables for activities, such as sports, woodwork, gardening, work placements, swimming and walks, are available in service users files. On the day of the visit a service user was going off to the gym, others were going to work placements, and some service users were staying at home. Those service users staying at home were undertaking household tasks; they said that the household tasks are shared among all of the people who live in the house and staff help them if they need it. The registered manager said the provider organisation employs a ‘job carver’ who helps service users to find work placements; he said that three service users are now settled into work placements and two have just had interviews. Surveys received prior to the Desboro House DS0000002351.V323320.R01.S.doc Version 5.2 Page 13 visit show that service users are able to choose their own activities at all times. Service users spoke enthusiastically about going to local seaside resorts, pubs and cinemas, and they said that they can choose what activities they like to do and where they want to go on holiday. There is evidence in records that staff encourage and support service users to maintain family contacts, and one service user said that they are able to phone their family regularly. They also said that they choose their own menus and there is always something else if anyone changes their mind. Observations during the inspection show that service users are free to make drinks and snacks whenever they want, they help to cook meals, and there is a good supply of fresh fruit and healthy eating foods around the house. A lunchtime meal was seen to be in line with health eating principles. Recipes are available to help service users make their choices, as well as take away menus. The registered manager said that each service user has the opportunity to engage in more in depth skill development by doing their own personal menu planning, cooking and shopping for a three-month period. Service users confirmed this during discussions and described how this will help them if they choose to move into semi-independent support services. Pre inspection information shows that there are policies available for food safety and nutrition. Desboro House DS0000002351.V323320.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, 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are assured that their personal and health care needs will be met, by way of thorough care planning, clear procedures and robust record keeping. EVIDENCE: Pre inspection information shows that policies are available for medication administration and first aid. There is also evidence in records held by the commission that any accidents and/or injuries are managed appropriately. Service user files contain health action plans, which say how the service user wants to be supported to meet their health care needs. Where necessary service users are supported to monitor their weight and this is recorded. Records are also kept of where service users are supported, for example, to manage daily foot care. Care plans are in place for areas such as immunisations, medication and attending well-person clinics, chiropodists and dentists. There are also care plans for support with personal hygiene, behaviour and emotional needs. There is general information available about service users individual health needs such as syndromes, and there is evidence Desboro House DS0000002351.V323320.R01.S.doc Version 5.2 Page 15 in records that staff receive training in specialist health care areas such as epilepsy. Service users said that they could see their GP or other health care professional when they wish or need to and they said that staff always help them to do this. One service user said that staff know how to help them and they understand their needs. Medication administration records are completed in full and there is a very clear and well-documented audit trail of medications from ordering to administration or disposal. As well as administration records, the audit trail includes daily checklists and stock sheets. There are detailed records for the use and administration of homely remedies and first aid, and the associated procedure ensures that managers are made aware of and agree the usage of homely remedies. A service user said that they feel safe with the medication procedures that are in place and risk assessments for self-administration of medication were seen in individual files. There is also a copy of the risk assessment kept with medication administration records. Desboro House DS0000002351.V323320.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, 23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are protected by comprehensive and accessible policies and procedures, and they are able to express their views in a responsive atmosphere. EVIDENCE: The complaints policy is available in service users files, and it is presented in written, sign language and DVD formats. During the visit service users said that they know how to make a complaint, feel safe with staff, and that staff listen to what they say. Service users also said that staff help them to sort out any problems they have and they can raise any issues they have at the house meetings. Surveys received prior to the visit show that all service users know who to talk to if they have a problem, and how to make a complaint. They also confirmed that staff listen to what they have to say and take action to help. No complaints have been made since the last inspection, however records are kept of any general concerns raised by service users, and the actions taken to address the matters. Service users have access to their care manager’s contact details and advocates details if they do not wish to raise complaints with the staff, and service users said that they know how to contact them. The registered manager said that an advocate from the local service takes part in regular meetings at the ‘Pointers Committee’, which is a service user representative committee for the wider provider organisation. There is also a regular advocate surgery held at a near by service. Desboro House DS0000002351.V323320.R01.S.doc Version 5.2 Page 17 Information about safeguarding adult issues, including a clear policy, is also available in the home, and staff demonstrated a very clear understanding of those issues. Pre inspection information and house records show that no safeguarding adult referrals have been made since the last inspection visit. This information also shows that there is a policy in place for whistle blowing. Desboro House DS0000002351.V323320.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, 28, 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service user enjoy a very comfortable environment that they have been fully involved in developing; and that suits their needs and wishes. EVIDENCE: Surveys received prior to the visit show that service users think the house is kept clean and tidy, and during the visit service users were undertaking cleaning tasks within the home (also see Standards 11-17). Other pre inspection information shows that since the last visit the home has been generally redecorated, the kitchen and upstairs bathroom have been refurbished, and there are new security lights in the grounds. The registered manager said that all radiators have been covered since the last inspection visit, and service users described how they had suggested that the garage space be turned into a useable room, which is now the dinning room, again at their suggestion. They said that they also helped to decorate the space, which was confirmed by the registered manager. Desboro House DS0000002351.V323320.R01.S.doc Version 5.2 Page 19 Service users said that they chose the colours, the furniture and the carpets in their bedrooms and they decide how they want it arranged. Bedrooms are well personalised and service users said that they were very happy with their rooms and have keys to the doors for privacy. There is a large well-kept garden, which has fruit trees, and service users and staff said that they use the fruit to make desserts. Observations show that the house is generally very well decorated and furnished, and has a homely and comfortable atmosphere. Maintenance records show that any issues are resolved in a timely manner. All substances that could be hazardous to health are stored appropriately, and gloves and aprons are available to staff. Records show that staff are trained in infection control procedures and the registered manager said that as a result of a recommendation made in another service area, they were now replacing communal hand towels in staff areas with paper towels. Desboro House DS0000002351.V323320.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, 35, 36 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff are well trained, well supported, and safely recruited; which assures service users that their needs will be met in a safe and informed manner. EVIDENCE: Pre inspection information shows that there are policies in place for recruitment and retention; and staff are trained in areas such as fire safety, medication, managing abuse, disability discrimination, equal opportunities, infection control, team building, first aid, health and safety and medication. House records confirm this and also show training in challenging behaviours and autism. They show that staff have access to training for nationally recognised care qualifications; and the registered manager said that it is an expectation of the organisation that staff undertake training towards the qualification within six months of commencing in post. He said that staff fill in their training files at staff meetings, as there are agenda items for issues such as policy up dates. Minutes of staff meetings also show that areas such as the operational plan, care plans and service user needs are discussed. Desboro House DS0000002351.V323320.R01.S.doc Version 5.2 Page 21 Induction records are in place and the programme includes an introduction to the house and the needs of the service users. The programme is in line with nationally recognised general and specialist frameworks; and probationary reviews are held at three and six month intervals. Staff files contain recruitment information such as identification, application forms, references and criminal record bureau checks. The records are detailed and well organised. The registered manager said that service users are involved in interviewing staff, and the provider organisation is currently assessing the possibility of service users being involved in the staff appraisal process. Rotas show that there is a consistent staff team, with any shortages being covered by staff from other areas of the organisation, who are known to the service users. Service users said that there is always enough staff to meet their needs, and the staff treat them very well. Staff demonstrated through observation and discussion that they have a detailed knowledge of service users needs. Staff said that the registered manager is very supportive, and encourages them and the service users to express their views. They said that there is good teamwork and they get regular supervision. They said that during supervision they can talk about any work issues and training needs. They said that they are supported to develop their skills and have very good access to training courses. They felt that this helps them to do the job well. Desboro House DS0000002351.V323320.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, 41, 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users benefit from a very well run home, in which their safety and welfare is protected. They are able to control how their care and support is provided and are fully involved in the development of the services they receive. EVIDENCE: Clear and detailed daily records are available, which say what the service user has done and how their care plans have been implemented. Service users said that they know what is written in the notes. Accident records are also clear and they cross reference with daily notes. Service users sign to say they have been involved in house meetings, and the minutes show that they discuss issues such as complaints, leisure activities and operational plans. They said that they can make things better in the house by attending the meetings, and they can also be involved in the wider organisation development through the Desboro House DS0000002351.V323320.R01.S.doc Version 5.2 Page 23 ‘Pointers Committee’ (also see Standards 22-23). They said that one person from the house attends and speaks on their behalf, then comes back and tells them what has happened. Throughout the visit service users demonstrated that they are very aware of all aspects of the running of the home and the issues that effect them. There is a comprehensive quality assurance process in place, which includes an annual service user, relative and other stakeholders satisfaction survey. The outcomes of the previous survey showed that everyone is generally very pleased with the services provided. There is a detailed monthly house audit carried out by a manager from another area within the organisation, and then an action plan is developed to address any issues highlighted. A recent monitoring visit by the Local Authority Contracting Department gave a positive overview of the house and the care provision and made no recommendations for improvement. The ‘Pointers Committee’ (see Standards 22-23) also conducts service user surveys about specific issues such as communication. Service users demonstrated a very clear knowledge of fire safety issues including the evacuation procedure and assembly point. On arrival at the house the inspector was shown the fire exits and told where the assembly point was in case there was a fire during the visit. There is an up to date fire risk assessment in place, and records show that there are monthly evacuation practices, weekly equipment and alarm checks, and monthly emergency lighting checks. Records show weekly testing of water temperatures, and weekly observation checks of wires, bulbs and plugs. Testing is carried out regularly on both personal electrical equipment and general house equipment, such as TV’s, hifi’s and hairdryers. Separate records are kept for the testing, with the personal equipment records being kept in service user files. There are records for regular boiler and Legionella checks. Pre inspection information shows that there are policies in place for substances that could be hazardous to health, quality assurance, equal opportunities, fire safety, record keeping and general health and safety. Policies for fire safety, communication and complaints are available in DVD format, and the registered manager said that DVD’s are currently being developed for bullying and person centred planning. There are also data sheets for substances that could be hazardous to health and environmental risk assessments. The risk assessments include issues such as the use of outside contractors, walking with hot drinks, use of aerosols, use of stepladders, power failures and wearing sharp jewellery at work. There is evidence that the risk assessments are reviewed on a monthly basis. Desboro House DS0000002351.V323320.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 4 2 3 3 X 4 3 5 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 4 25 3 26 X 27 X 28 4 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 4 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 4 X 3 4 X Desboro House DS0000002351.V323320.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. Refer to Standard Good Practice Recommendations Desboro House DS0000002351.V323320.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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