Care Home: Halcyon Days

What the care home does well "We are well looked after, there`s no question about that" was one, very typical comment made to us during this inspection visit by a person who lives in Halcyon Days. The atmosphere in the home was pleasant and calm throughout and the standard of care observed was never less than very good, with easy and appropriate interaction between the staff team and those people who live in Halcyon Days. "If I can`t live in my own home, this is the best place I could be" was how one person living in the home expressed their sense of contentment.The manager indicated that the home tries to be `person centred` in everything it does and this statement was supported by the care records seen, which bring people who live in the home `alive` as individuals with biographical details and clear information about how they like things done and what they don`t like which then determines how their care is given and how they are supported by staff. This makes the care experience for people living in the home a more individualised and personally tailored one than would otherwise be the case. People living in Halcyon Days benefit from the home`s pleasant and wellmaintained environment, and virtually everybody spoken to mentioned how much they enjoyed the extensive and well cared for grounds and gardens. As well as being consistently praised by people living in the home, the staff team under the manager were very positive about the work they do and the support they receive in training and supervision. This means that people living in Halcyon Days benefit for a well trained and motivated staff team. What has improved since the last inspection? Any requirements made following the inspection of June 2007 have been met. People living in Halcyon Days now benefit from some innovative changes that have been made to the menu and ad hoc catering arrangements, which mean that they have ready access to snacks and more substantial food outside of the `standard` meal times. People who live in Halcyon Days now have more opportunity to meet together and influence the way that the home is organised and run and have selected one of their number to represent them more formally, potentially including the process for the recruitment of staff. There has been some adjustment to staffing and staff availability at key times to try and reduce inconvenience to people living in Halcyon Days and to make their routine care experience a better match to their expressed wishes. CARE HOMES FOR OLDER PEOPLE Halcyon Days The Old Rectory Church Lane Graveley Nr. Stevenage Hertfordshire SG4 7LU Lead Inspector Jeffrey Orange Unannounced Inspection 24th June 2008 07:55 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 Halcyon Days DS0000019403.V367025.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. Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Halcyon Days Address The Old Rectory Church Lane Graveley Nr. Stevenage Hertfordshire SG4 7LU 01438 315588 01438 312587 managerhalcyon@goldcarehomes.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Karlamain Limited Dawn Richmond-Cook Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability over 65 years of age (3) of places Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th June 2006 Brief Description of the Service: Halcyon Days is registered to provide care and accommodation for up to 33 older people. It is a detached, late Victorian building that has been sympathetically extended to create the current home. Bedrooms are located on the lower ground, ground, first and second floors, and are mainly offered for single occupation. There are two lounges, a reception seating area and two dining rooms. The office, kitchen and hairdresser’s room are located on the ground floor. The home has adequate bathroom, shower room, and toilet facilities to meet the requirements of people living in Halcyon days. The laundry and extensive storage area are located in the lower ground floor. The home stands in three acres of mature landscaped grounds and offers fine views over the surrounding countryside. It is located in a quiet rural area on the outskirts of the village of Gravely and the towns of Stevenage and Hitchin are easily accessible by public transport. Prospective service users are provided with a copy of the home’s Statement of Purpose, Service User’s Guide and the latest copy of the home’s newsletter. The latest inspection report from the Commission for Social Care Inspection is available and on display. Fees correct at 24/6/08 range from £420-£600 per week. Additional charges are made for hairdressing, chiropody, newspapers and personal toiletries. Halcyon Days DS0000019403.V367025.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 inspection took place over approximately 6.5 hours beginning early in the morning, which gave us an opportunity to see the experience of people living in the home as they were helped to get up, have their breakfasts and generally get ready for the day ahead and also to observe the morning and lunchtime routine in the home. During the inspection it was possible to speak to people who live in the home about their experiences and to speak to members of the staff team and the home’s manager about their roles and their views on how the home operates and is managed. We also looked at some key records, including those for medication, staff recruitment and training and care plans for people living in Halcyon Days. This report also draws on information received from surveys completed by people living in the home or from members of the staff team. Where we receive surveys after this report is finalised, we will record and assess them and take any action indicated as necessary by them. We have also made use of information provided by the home in their annual quality assurance assessment or AQAA. The AQAA is a self-assessment document that focuses on how well care outcomes are being achieved for people living in Halcyon Days and also includes some useful statistical information about the home. What the service does well: “We are well looked after, there’s no question about that” was one, very typical comment made to us during this inspection visit by a person who lives in Halcyon Days. The atmosphere in the home was pleasant and calm throughout and the standard of care observed was never less than very good, with easy and appropriate interaction between the staff team and those people who live in Halcyon Days. “If I can’t live in my own home, this is the best place I could be” was how one person living in the home expressed their sense of contentment. Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 6 The manager indicated that the home tries to be ‘person centred’ in everything it does and this statement was supported by the care records seen, which bring people who live in the home ‘alive’ as individuals with biographical details and clear information about how they like things done and what they don’t like which then determines how their care is given and how they are supported by staff. This makes the care experience for people living in the home a more individualised and personally tailored one than would otherwise be the case. People living in Halcyon Days benefit from the home’s pleasant and wellmaintained environment, and virtually everybody spoken to mentioned how much they enjoyed the extensive and well cared for grounds and gardens. As well as being consistently praised by people living in the home, the staff team under the manager were very positive about the work they do and the support they receive in training and supervision. This means that people living in Halcyon Days benefit for a well trained and motivated staff team. What has improved since the last inspection? What they could do better: Because the home has an exceptionally focussed and proactive manger and staff team it is hard to think of an area where improvements might be made that has not already been identified by the quality assurance process that is in place in order to ensure that the high standards experienced by people living in the home are maintained. Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 7 As already identified by the provider some work is required to ensure that the information that is provided in the Statement of Purpose and Service User Guide is up to date so that people receive the most recent and relevant information about the service. It is important to the safety and quality of life of people living in Halcyon days that medication administration and social and day time activities are maintained at the current level at least and in the case of social activities that the staff team constantly seek ways to develop the home’s programme in order to improve it still further. 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. Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 8 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 Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 9 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): 1, 3 & 5 (Standard 6 does not apply to Halcyon Days) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering Halcyon Days as a home for themselves or someone they are responsible for can be assured that they will have the basic information they need to make a reasonably well informed decision, although additional detail about how the diverse needs of prospective residents will be met and improved formats for the information would make this process more effective. People being assessed with a view to moving into Halcyon Days can be assured that they will only be admitted if their care needs can be met in a way that reflects their personal requirements and wishes following a thorough and robust process of assessment. Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home’s AQAA has identified the need to update the brochure about the home and the service user’s guide. It has been indicated that this process will include consultation with, and the involvement of people living in the home to make sure it reflects their views and experiences. In looking at the Statement of Purpose and Service User’s Guide it was found that some of the contact details given for the Commission for Social Care Inspection (CSCI), including in the complaints procedure were out of date. It was also found that reference is made to ‘nurse’ call bells, which could be misleading as Halcyon Days is not registered to provide nursing care. Relatives of people living in the home tell us that they have been able to visit the home before any decision was made about admission. This is important as in many cases the individuals concerned leave the choice of home to other people, often family carers, and they need to be confident that they will be able to see what the home is like and whether they think the person for whom they are making the decision will be happy there and that their needs will be met. We looked at some pre-admission assessments for people who had recently moved into the home, these were very full and detailed and provide confidence that only those people whose needs can be appropriately are being admitted. Anyone considering Halcyon Days as a home for themselves or someone they are responsible for can be certain that they will be given every opportunity to visit the home in order to make sure that it is a place that they will feel comfortable living in. When we talked to people living in Halcyon Days the overall level of satisfaction with the care provided was very high; “The girls (sic) are very caring and will come and sit with you if you want them to” was one of many positive comments made. Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 11 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): 7, 8, 9 & 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who live in Halcyon Days can be certain that they will receive effective personal and healthcare support and will experience a person centred approach from staff that recognise their rights in respect of dignity, equality, fairness and respect. Those people who live in Halcyon Days and rely on staff to assist and support them with their medication can be assured that the home has effective medication policy, procedure and practice guidelines which are routinely monitored to ensure that they are carried out in a way that protects them and maintains their health and safety. EVIDENCE: During this inspection we saw staff consistently treating people living in the home appropriately, with respect and involving people living in home in decisions about their care and how it was to be given. Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 12 When we looked at care plan documentation, we found evidence of people living in the home being able to access community health services such as hospitals and clinics and those that require a visit in the home have received them. Peoples needs are set out in a care plan that focuses on them as an individual and ensures that the staff who provide care for them have the information they need to do so in a way that reflects their preferences and personality. We found that the care plan format was easy to read, very informative and provided staff with good information about the life and experience of people living in Halcyon Days. This all contributes to understanding the individuality of people receiving care and ensures that staff have not only the technical information they need but also the information that ensures they can provide care in a way that is tailored to the person concerned. When we checked medication records and procedures we found that they were of a good standard, accurate and well maintained. This helps to maintain the health, safety and welfare of those people who need help with their medication Halcyon Days DS0000019403.V367025.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): 12, 13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who live in Halcyon Days can be assured that they will be supported and encouraged to enjoy a stimulating lifestyle with a variety of options to choose from. Routines, activities and plans are person centred and flexible and are reviewed regularly so that people living in Halcyon Days can be reassured that if their needs or preferences change, this will be reflected in practice. People living in Halcyon Days can be assured that they can have meals at flexible times and in a variety of locations according to their wishes each day. EVIDENCE: When we spoke to people living in Halcyon Days they told us that there were activities for them to choose from “most days if not every day” Care plans that we saw included activities records and details of the individual interests and concerns of people living in the home and how these were to be reflected in their care. Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 14 The home have become members of a national association that works to improve and advise on activities in care settings which demonstrates tangible commitment to developing the home’s activity programme for the benefit of the people who live there. The home’s AQAA also identifies the need to develop more activities in the evening to spread the time that specific activities are available for people to take part in if they choose to do so. On the day we visited the home we were able to see staff engage on a one to one basis with people living in the home, when we spoke to one person sitting in the hallway, they said that they were waiting for someone to take them for a walk and we then saw a member of staff come and take that person to walk in the grounds. Communal areas had drinks set out and we saw staff offering these to people who were not able to help themselves, there were crisps and snacks set out in communal lounges, which people could help themselves to along with fruit. We saw a ‘Nite Bite Menu’ which lists snacks and light meals that are available to people living in the home outside of ‘usual’ meal times, for example between 7pm and 7 am, this includes scrambled egg, ravioli, sandwiches and soups, cereals and various things on toast. This means that any person living in Halcyon Days can have something to eat throughout the day and night if they choose to. We spoke to a person who has been selected by other people living in the home to be one of their representatives on a new ‘resident’s Committee’, they were quite excited by this and looked forward to the first meeting. We saw records of survey results and the action that was taken as a result of comments made, and we also saw minutes of a residents meeting, attended by 19 of the people living in the home at which a whole range of issues were discussed. There was evidence seen of action taken for example the inclusion of liver and bacon in the menu “I love it “ was the comment recorded. There are now communication books in each room for relatives and others to report things or make comments and there have been new choice forms introduced which people living in the said had made making choices about food, for example, much easier. Additional dining space had been created in the small lounge for those who preferred to eat in smaller scale settings and on the day of this visit several people were having their lunch in the garden, in the newly created patio area. They told us that they loved being outside and paid particular tribute to the home’s gardener for the way he kept the grounds. Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 15 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): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in Halcyon Days and those who are responsible for them can be confident that the home provides a safe and understanding environment in which they can freely express their views and any concerns they may have, without repercussions for themselves or those they are responsible for. People living in Halcyon Days can be assured that staff working in the home are supported through training to be able to recognise actual or potential abuse and to know what action to take if it is seen or suspected and this should safeguard the well being of people living in the home. EVIDENCE: We found that staff training records include safeguarding (adult protection) training and that the Hertfordshire County Council safeguarding procedure is available in the home for staff to follow in the event that a safeguarding referral has to be made. When we talked to staff during this inspection they had a good understanding of what constitutes abuse and also they recognised the term ‘whistle blowing’ which suggests that they would feel able to raise any concerns outside of the home if they felt they needed to. This level of awareness provides confidence that the people who live in the home are not at risk from staff not knowing how to recognise abuse or what to do if it is seen or suspected. Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 16 The home has a complaints policy and procedure that is clear and accessible and which should provide people with confidence that any complaint they make will be listened to and taken seriously. The contact details for the CSCI were out of date in the copies seen of the complaints policy included in the home’s Service User Guide and Statement of Purpose. Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 17 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): 19, 20 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who live in Halcyon Days can be assured that they will experience a physical environment that provides for their individual requirements appropriately and is clean, safe, comfortable and well maintained. They can be confident that they will have access to a range of communal areas, both inside and outside of the home, which will provide them with a real choice when deciding where they would like to sit and relax or join in activities if they prefer. EVIDENCE: “The grounds are wonderful” was only one of very many comments we heard as people living in the home talked to us about the environment. Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 18 We were able to talk to some people living in the home as they sat outside having their lunch on the newly laid patio area and other people told us how much they enjoyed being able to walk in the grounds. The lounges and dining areas in the home were found to be well used by different people at different times of the day and the addition of a dining area in the smaller of the home’s lounges has enabled some people to have their meals there as an alternative to the larger dining room. When we talked to people in their own rooms, the rooms were seen to be personalised with their own possessions including several with collages, made with the help of the home’s activities staff and relatives, to reflect the interests and life history of the individuals concerned. The bathrooms seen were well presented and provide the kind of environment that people living in the home told us they found attractive and pleasant to use. The entrance hall of the home was seen to have been given a new floor and furniture to make it safer and more accessible for people who choose to sit there, as several were seen to be on the day we visited. The home’s AQAA has identified areas where further development and improvement may be possible including provision of an area in the home where people living in the home and visitors can make their own refreshments if they wish to do so. The home was free of any unpleasant smells on the day we visited and people living in the home we spoke to told us that this was usually the case. “It is kept very clean” one person commented. Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 19 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): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in Halcyon Days can be assured that any care they require will be provided by well trained and supported staff, in the numbers necessary to achieve good care outcomes for them and who have been subject to a robust recruitment process to ensure that they are fit to do so. EVIDENCE: When we spoke to members of the staff team they told us about the training they had received, including at level 2 and 3 NVQ in care. This, together with records of training given and due in future, demonstrates that staff have the skills they need to provide care to the people who currently live in Halcyon Days. Staff told us that their formal one to one supervision is undertaken regularly and this means that staff receive the support that they need to be able to identify any training or development needs, to reinforce good practice and provide them with an opportunity to discuss those people living in the home for whom they are key workers. When we spoke to people living in the home about the staff, they were extremely positive “ they are very caring and kind” and “nothing is too much trouble for them” were only some of the comments made. Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 20 Recruitment records were seen to include evidence of the checks needed to protect people living in the home from receiving care from people who may not be suitable or safe to do so. When we spoke to staff in private, they were significantly very supportive of the home, its manager and their experience of working there. “I love being here”, “Its good”, “they (the management) listen to you and take action” “I’ve learnt a lot” were only some of the comments made. It follows that people living in the home benefit from receiving care from staff who want to be there and enjoy what they are doing and are given the training and support they need to help them care effectively and efficiently. The manager told us that the number of staff available in the home at key times has been increased to help improve the care experience of people living in the home at those times when staff are under the most pressure. Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 21 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): 31, 32, 33, 35, 36 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in Halcyon Days can be confident that they live in a well managed home where their wellbeing and best interests are paramount in decisions made. Staff working in the home can be confident that they will be well supervised and supported to help them meet the care needs of people living in the home. EVIDENCE: It is understood that the home is not involved with the personal finances of people living in the home. Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 22 When we spoke to staff they told us that the manager and her deputy are open and supportive and that they welcome suggestions as to how the standard of care might be improved. The Manager completed the AQAA very thoroughly and it included analysis of how various areas of the home’s activity might be further improved. This, together with evidence seen of regular quality assurance processes demonstrates a genuine commitment to improvement that can only be to the benefit of people living in Halcyon Days. When we spoke to people living in the home, they confirmed how active the manager in particular is, and these comments were substantiated by minutes seen of meetings held with people living in the home, with reports of surveys undertaken to get feedback from people living in the home and from plans already in place for increased representation by people living in the home in day to day decisions as well as, for example the recruitment process for new staff. Care plans that we looked at included a robust framework of risk assessment to identify any risks to the health, safety and well being of people living in the home and how they can be reduced or eliminated. This should provide people living in the home with confidence that their health and safety is being safeguarded. In discussions with the manager and from feedback received from both staff and people living in the home, it is clear that the manager, as well as being well qualified and still undertaking additional training and personal development in order to acquire new skills and update existing ones, is personally absolutely committed to the home, its staff and above all the people who live there. This benefits everyone who either lives or works in Halcyon Days. Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 23 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 2 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 4 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 3 3 X 3 Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 Refer to Standard OP1 Good Practice Recommendations In order to make sure the Service User Guide and Statement of Purpose are as clear and informative as possible, priority should be given to reviewing them, their content and accuracy and also their format to see if they could be improved. Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Halcyon Days DS0000019403.V367025.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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