Care Home: Elizabeth House

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What the care home does well The home has a calm and relaxed atmosphere. Staff are kind and caring, and put the needs of people living in the home first. The management of the service is ensuring improvements to the service are taking place. The home is accessible, safe and well maintained. What has improved since the last inspection? Improvements since the home opened have included better monitoring of the arrangements to administer medicines. The home has recruited more permanent staff. The home is providing transport to better enable relatives to visit people living in the home. What the care home could do better: The contract/terms and conditions of residence for people living in the home does not at present include all required information. Care plans are not including a concise summary of the care to be provided which would be easily consulted and available to the staff providing the care, and to the person receiving the care and their representative. Arrangements for protecting people from abuse would be improved by ensuring that the checks for agency staff include the dates of the CRB check and the PoVA check, and by ensuring that agency staff employed have undertaken statutory training which is regularly updated. CARE HOMES FOR OLDER PEOPLE Elizabeth House Victoria Drive Bognor Regis West Sussex PO21 2TB Lead Inspector Ed McLeod Unannounced Inspection 20th November 2007 09:30 X10015.doc Version 1.40 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 Elizabeth House DS0000070568.V353362.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 Older People. 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. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elizabeth House Address Victoria Drive Bognor Regis West Sussex PO21 2TB 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) 02920 364411 Shaw healthcare Ltd Post vacant Care Home 31 Category(ies) of Dementia (0) registration, with number of places Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category only: Care home - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Dementia (DE) The maximum number service users to be accommodated is 31 Date of last inspection New service Brief Description of the Service: Shaw healthcare was registered on 9th August 2007 to provide accommodation at Elizabeth House for up to 31 people, male or female, who come within the category of dementia. The person registered with CSCI on behalf of the company for the service is Mr Peter John Jeremy Nixey. The manager registered with CSCI for the service is Mrs Susi Garland. The home is situated in a suburban area of Bognor Regis in West Sussex, and is within about a mile of town centre shops and also bus and train connections. The fees are £444.29 per week. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was arranged to undertake an assessment of key standards for this service which was registered in August 2007 and has not previously been inspected. Preparation for the visit included obtaining the provider’s CSCI annual quality self-audit (the AQAA). Also, the people living in the home, their relatives or representatives, and staff were asked to complete survey forms. The visit was undertaken by one inspector on the 20th November 2007, and we were on the premises for six and a half hours. During the visit we talked to people living in the home, staff members and the acting manager. We observed interaction between people living in the home and staff, and observed a lunch sitting. We visited some bedrooms and the communal areas of the home, the kitchen and laundry room. We sampled 3 sets of admission records and care plans, and other care records such as food and fluid charts and risk assessments. As part of our assessment of the safety of people living in the home, we sampled 3 sets of permanent staff recruitment and training records and 3 sets of agency staff recruitment and training records. This report has incorporated information from the above sources. What the service does well: The home has a calm and relaxed atmosphere. Staff are kind and caring, and put the needs of people living in the home first. The management of the service is ensuring improvements to the service are taking place. The home is accessible, safe and well maintained. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 6 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. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have their needs assessed before admission is agreed. Information on the service is provided to people living in the home and others, but the contract/terms and conditions of residence does not at present include all required information. Intermediate care is not offered in the home. EVIDENCE: The manager has told us that people are invited to visit the home and receive information to assist them making an informed choice, and that pre-admission assessments are carried out by the home. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 9 A statement of purpose and a service user’s guide are provided which give information on the service for people living there and people looking for a placement. Three sets of care plans sampled indicated that the person’s needs are being assessed before admission is arranged. We sampled some of the contracts/terms and conditions of residence between the home and people accommodated, and found that these did not include required information such as the fees payable and by whom, and the rooms to be occupied. Training is in place to support the staff team’s understanding of dementia, and interactions observed between staff and people living in the home demonstrated that staff have understanding of the impairment caused by dementia. Short term intensive rehabilitation which enables a return home (intermediate care) is not provided. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are not including a concise summary of the care to be provided which would be easily consulted and available to the staff providing the care, and to the person receiving the care and their representative. People have access to the health care services that they need. For the better protection of people in the home the service has been improving the monitoring of medication records and procedures. EVIDENCE: The home had told us in their annual CSCI self audit quality assessment (AQAA) that care plans now contain more information relevant to the needs of people living in the home. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 11 We discussed with the acting manager Mrs Bennett the high levels of needs for people living in the home which was apparent through the information provided in the AQAA. Mrs Bennett advised that some of the people living in the home at the time the AQAA was completed had now been assessed as needing nursing care, and more appropriate placements had now been found for them. We looked at care plans for three of the more frail people living in the home, which told us that people’s needs are being regularly reviewed, risk assessments are in place, and people’s preferences for how they wish their care to be provided are recorded. There was also evidence that relatives can attend reviews of the care plan, and therefore contribute to the planning of their relative’s care. Some of the information and guidance provided in the plans of care was however contradictory. For example, for one person who is often awake and wandering at night, or chooses to sleep in a chair, the guidance for staff on how to respond to this was very different in three different documents on the care plan. This indicates that the person may not be receiving a consistent approach to her care. It was also our view that the spread of documents in the care plan, amounting sometimes to twenty pages or so, lacked a concise summary of the plan of care which would be easily consulted by staff providing the care and by the person receiving the care or their relative or representative. Care plans sampled indicated that people were accessing the health care services they were in need of, such as chiropody, medication reviews and mobility needs. While charts for fluid and food intake were seen for people where this needed to be monitored, the records were sometimes vague. For example, for one person the recommended fluid intake was 2 litres per day, but records were not sufficient to indicate if the person had been receiving 2 litres of fluid each day, and therefore it was not clear if this part of the care plan was being met. Staff interviewed told us that only team leaders take responsibility for administering and recording medicines, and staff undertake training and assessments in this. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 12 The home has introduced more regular medication audits and record sheets are checked every day and signed by two team leaders. Arrangements are in place for the disposal of medicines and of sharp objects. Where a mistake in giving medicines has taken place, records seen advised of the mistake and the action taken subsequently. We discussed with staff the arrangements in place for the regular review of medication for people living in the home, and we were advised this is usually undertaken by the local community health team. Staff said the need for more regular reviews of medication for each person was presently being considered. Interactions observed between staff and people living in the home indicated that staff recognised the need for people in the home to have their privacy and dignity observed, and the atmosphere in the home was found to be supportive and friendly. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s social and recreational interests are being encouraged, and there is a friendly atmosphere. People are supported to maintain contact with their relatives and, where they wish, with local churches. Meals are balanced and nutritious, and are taken in a congenial setting. EVIDENCE: The manager advised that a weekly gentle exercise session is provided, and musical entertainers visit the home. On the day of the inspection visit, a singer was entertaining a large group of people in one of sitting rooms, and people were enjoying joining in the singing and dancing. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 14 The acting manager said that an activities co-ordinator had started on 19/11/07, and it was expected that this would lead to people in the home being offered a wider range of activities. Outings since the home was opened in August 2007 have included shopping trips, and the acting manager acknowledged that outings was something they could do more of. We looked at the social care needs identified in one care plan, and discussion with staff provided examples of how those needs are being met. We observed that most people in the home were choosing to spend time in the communal areas and we observed many staff spending time with them – for example sitting and chatting or accompanying people on walks around the building. The day of the visit did not have good weather, but staff told us that in good weather residents enjoy walking around the garden paths. Arrangements in the home to support people with their religious beliefs include a church visitor providing communion for people who are Roman Catholic. Staff we talked to gave examples of this taking place. In a CSCI survey form returned to us by a relative, one comment was that staff were “always ready to answer any questions raised and always very welcoming to visitors”. A room is provided for anyone who wishes to remain overnight if their relative is poorly. Some people are being assisted to maintain contact with their relatives through the provision of transport by the home. Although many of the people in the home have severe impairments, staff were observed doing what they could to ensure people were presented with choices. One relative commented on their survey form that staff were putting the needs of the residents first. We observed a lunch sitting which was relaxed and sociable, and people who needed help at the table were receiving this in a kind and patient way. One member of staff was observed spending ten minutes with a person who was agitated until they were ready to sit at the table. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 15 Where people had difficulty making a choice from the lunch options available, staff were bringing the options to the table so the person could better choose. The meals being served indicated that a balanced and nutritious diet is being provided. Staff told us that people with diabetes were being catered for, and there was always a diabetic choice of sweet at each meal. The manager told us in the AQAA that people living in the home have a menu with the choices available, and that kitchenettes provide drinks and snacks at other times. We are advised that specialist diets are catered for and all food is freshly cooked on the premises. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s complaints are being taken seriously and acted upon. People are being protected from abuse. EVIDENCE: A policy and procedure for the making of complaints is in place. We looked at the complaints record and found that where a complaint had been made the investigation, outcome and response to the complainant was recorded. Further to the introduction of the Mental Capacity Act, the manager tells us in the AQAA that where a person lacks capacity an advocate is appointed. Care plans sampled included one where an advocate under the Mental Capacity Act had been appointed for the person. Training records sampled indicated that staff are receiving training in safeguarding vulnerable people from abuse. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 17 In a CSCI survey response received, a member of staff wrote to us that “training in dementia and challenging behaviour have been especially helpful”. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe well maintained environment, with access to comfortable indoor and outdoor communal facilities. Good toilet and washing facilities are provided. People live in safe, comfortable bedrooms with their own possessions around them. The home is clean, pleasant and hygienic. EVIDENCE: Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 19 Elizabeth House was opened as a new home in August 2007 and has been newly furnished and equipped to a good standard. The environment and the grounds are being kept in good order, and a worker is employed in the home to assist with maintenance work. There is a system in place to ensure maintenance issues are attended to. For example, in their survey form one member of staff said that the sitting room windows did not have blinds, which meant that too much direct heat and sun for the comfort of residents at times. The maintenance records showed that this had been requested. Other maintenance needs had been attended to, and were being dated and recorded in the maintenance book. In the AQAA the previous manager told us that signs are now in place directing residents to the lounge areas from their bedrooms and people have a name plate on their bedroom door. The acting manager said a colour scheme to help orientation was also being considered. All bedrooms visited had en suite showers and toilets, and some of them had been personalised by people – for example, with items of their own furniture, photographs and other possessions. The sitting rooms and dining areas provide a comfortable living space for people. There is a nice garden with garden furniture and walks to help people enjoy the outdoors. Communal bathrooms seen were appropriately equipped to meet the needs of the people living there. All areas of the home visited, including the kitchen and laundry areas, were found to be clean and fresh. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing numbers provided are meeting the needs of people in the home. Staff in the home are being supported to undertake recognised care qualifications. For the protection of people living in the home, more detailed recruitment records should be obtained for temporary (agency) staff working in the home, who must be undertaking statutory training which is regularly updated. A permanent staff team who are undertaking statutory training which is regularly updated is supporting people in the home. EVIDENCE: On the day of our visit, it was our observation that staff numbers on each unit were adequate to meet the needs of the people living there. Staff did not appear to be rushed, and were able to take the time with the individual resident that they needed. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 21 Staff took time to talk with residents and go for walks with those who wished to. When a singer was entertaining during the afternoon, staff were dancing with people and singing along with them. A lunch was observed, and there were enough staff present to ensure that everyone who needed assistance with eating or cutting up food was receiving this. In the AQAA, the manager advises that 98 care shifts were worked by agency staff over a three month period. Staff rotas sampled during our visit indicated that 14 agency shifts were planned for the week commencing 18th November 2007, and 16 agency shifts were planned for the week commencing 25th November 2007. In survey forms from members of staff we received comments such as “it’s sometimes hard working with agency (staff) that don’t know a lot about dementia” and “the care has been covered mostly by agency staff and a large percentage of this staff could not care less about the residents’ needs”. Survey forms from relatives of people living in the home included comments such as “agency staff are a mixed bag – some brilliant and others appear to not have a clue”. We discussed with the acting manager that employing such large numbers of agency staff can undermine the consistency of care provided for people. The acting manager told us that new, permanent staff were starting that week on their induction training, and that further care staff interviews were planned. We therefore considered that this would reduce significantly the numbers of temporary staff employed in the home, and therefore no requirement has been made concerning this. One relative said in their CSCI survey form that staff were “always ready to answer any questions raised and always very welcoming to visitor”. The AQAA tells us that of 26 care staff in the home, 11 have achieved the National Vocational Qualification (NVQ) in care at level 2 or above, and that 13 staff are working towards NVQ2 or above. The manager tells us that all new staff undertake induction training and a 4 day training in statutory topics before they start caring for people in the home, Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 22 and examples of this were seen during our visit. The AQAA also tells us that all staff have attended training in dementia care and challenging behaviour. We are advised in the AQAA that all catering staff have undertaken training in safe food handling, and 97 of care staff have done this training. Training records sampled indicated that staff were undertaking in-house training which covered the care and health and safety topics that would be expected, and that staff were updating this training on a regular basis. We looked at recruitment records for three permanent members of staff, and found that all required checks, references and identifying information had been obtained. We looked at recruitment records for three members of agency staff who have recently worked shifts in the home, and found that records did not include the date of the CRB check, and whether or not a PoVA check had been obtained. The records for one of the agency staff indicated they had undertaken only first aid training in January 2005 and manual handling training in May 2006 – therefore statutory training such as safeguarding adults, food hygiene and infection control had not been completed. Shaw healthcare’s policy on employing agency staff advises that “training must include statutory training which has been regularly updated”. It is our concern that staff who have not undertaken regular statutory training and full checks may be presenting a risk to people living in the home. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being run and managed in a manner which indicates shortfalls in the care provided can be addressed. The home is run in the best interests of the people living there. Arrangements are in place for all staff to be receiving formal supervision on a regular basis. EVIDENCE: Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 24 At the inspection visit, we spoke to acting manager Mrs Sue Bennett, who is on secondment until February 2008 from managing another Shaw healthcare home. Mrs Bennett told us that Mrs Garland, the present registered manager for the home, had worked her last day on 16.11.07. Mrs Bennett advised that an experienced new manager has been appointed and will take over management of the home in February 2008. Improvements to the service such as the monitoring of medication, an active staff recruitment process, and the provision of transport to support people in the home receiving visits from their relatives, indicates that the home is being managed well. On the day of the inspection visit, there was a good atmosphere in the home and staff were taking a positive approach to their work. CSCI survey forms received from staff and relatives indicated that they felt the home was being well managed, and that the home was being run in the best interests of people living there. . Mrs Garland tells us in the AQAA that “due to the level of mental impairment that most service users have it is not always possible to obtain their views about the service provided. For this reason relatives and advocates of service users have the opportunity to attend monthly resident/relatives meetings where they can air views and question any practices which they require further information about”. Mrs Bennett provided examples of relatives’ suggestions on how to improve the service which had been acted upon. Mrs Bennett advised that survey forms had been given to relatives and others, and which were beginning to be returned. We looked at records for the monthly visits carried out by the provider on 28/9/07 and 6/11/07, which indicated that the provider is seeking further improvements in the service. Maintenance records sampled included insurance cover which includes liability insurance. We looked at supervision records for three permanent members of staff. We found that supervision records indicated that in the three months since the commencement of the service, two of the staff had received supervision once, Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 25 and the third member of staff had not received supervision. All staff concerned were working on the day of the inspection visit. Mrs Bennett advised us that refresher training for team leaders in facilitating good supervision was to be provided. Mrs Bennett said the plan was for all staff to be receiving regular supervision as soon as possible. We took the view that arrangements were in place for staff supervision, and therefore no requirement was made concerning this. The AQAA tells us that relatives are issued with a receipt when monies are paid into a resident’s account, and receive a copy of any expenditure. In the AQAA Mrs Garland has advised us of when required policies and procedures have been most recently updated, and the most recent health and safety services, checks and inspections which have been carried out. We sampled maintenance records held in the home, which concurred with the information received, and we sampled the home’s monthly environmental safety audit. We visited the kitchen and found that food, fridge and temperature records were being maintained, and all food in the fridge was date-labelled. Kitchen cleaning rotas were sampled. The cook told us that the Safer Food system is not in place, but said that a recent Environmental Health visit had concluded that necessary checks had been carried out. The cook thought the benefit of using the Safer Food system is that it would bring the diverse checks together in one folder. In the AQAA the manager tells us that fire alarms are tested weekly, and regular emergency lighting and water temperature checks are being carried out. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 27 N/a 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 OP2 Regulation 5 5A Requirement All people living in the home or their representative must receive a contract/terms and conditions of residence which includes required information such as the fees payable and by whom, and rooms to be occupied. Care plans should include a concise summary of the care to be provided which would be easily consulted and available to the staff providing the care, and to the person receiving the care and their representative. Timescale for action 31/01/08 2 OP7 15 31/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 28 No. 1 Refer to Standard OP29 Good Practice Recommendations Recruitment records for agency staff should include the date of the CRB and whether or not a PoVA check has been obtained. Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Elizabeth House DS0000070568.V353362.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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