Care Home: Jonathan House

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What the care home does well People are supported through individual and person centred care planning and staff are provided with comprehensive information in order to meet peoples assessed needs.People are supported well in accessing individual opportunities to lead active and fulfilled lifestyles that are both appropriate and reflect their levels of independence. There is an open atmosphere in the home with staff supporting people to communicate their wishes and preferences. Comments received from relatives through surveys identified areas where the home does well `the home tries hard to help people achieve goals and encourages people to `stretch`` and `Being there when reassurance is needed about problems` and `Gives the right environment for the development or good life style` What has improved since the last inspection? The home has improved in keeping appropriate records with written risk assessments for safeguarding individuals health and safety, alternative foods offered and bank staff induction checklists. People now have written agreements consenting to being supported with the administration of medication. What the care home could do better: Keep a record of when `as required` medication should be administered. CARE HOME ADULTS 18-65 Jonathan House 19 Bayswater Avenue Westbury Park Bristol BS6 7NU Lead Inspector Sarah Webb Unannounced Inspection 28th November 2007 09:00 Jonathan House DS0000026539.V351642.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 Jonathan House DS0000026539.V351642.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. Jonathan House DS0000026539.V351642.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jonathan House Address 19 Bayswater Avenue Westbury Park Bristol BS6 7NU 0117 9736361 F/P 0117 9736361 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) Freeways Trust Ltd Miss Deborah Mary Cowap Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Jonathan House DS0000026539.V351642.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home providing personal care only - Code PC To service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability not falling within any other category - Code LD The maximum number of service users who can be accommodated is 8. Date of last inspection 8th November 2006 Brief Description of the Service: Jonathan House is operated by Freeways Trust Limited and is registered with the Commission for Social Care Inspection to provide accommodation and personal care for up to eight persons aged between 18 and 64 years, who have a learning disability. The home aims to support individuals within a community setting to lead as independent a lifestyle as they wish. Jonathan House is a mature three storey terraced house that is situated in a residential area in the North of Bristol that blends in well with the immediate environment. There are eight single bedrooms over three floors and the stairs are the sole means of access to each floor. This home would not be suitable to individuals with mobility issues as the lounge is on the first floor. It is close to local amenities including shops, a cinema, local bus routes, a church and a large common land, the Downs, which is used for a variety of recreational purposes. The current range of fees are from £483.89 to £630.00 Jonathan House DS0000026539.V351642.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. The purpose of the visit was to review the progress made to meet the requirement and recommendations from the inspection in November 2006 and monitor the care provided to the people living at Jonathon House. The inspection was conducted over 7 hours and the inspector had an opportunity to meet and talk with several of the people living at the home, the assistant manager and two members of staff. There have been no additional visits during this period. The home has been keeping us informed of incidents that affect the wellbeing of people and the provider has sent monthly appraisals of the service. The inspection process included looking at records including care and support plans, risk management, the administration of medication, and staffing. Further information was also provided through the homes Annual Quality Assurance Assessment. (AQAA) A tour of the home was undertaken and interaction between staff and people was also seen An expert by experience from People First, an advocacy agency for people with learning difficulties, visited the home during the inspection and helped with the inspection process. They spoke with people independently of the inspector and gained peoples views of their experiences of living at Jonathon House. Their findings are incorporated in this report. Surveys asking for views were received by 7 people using the service, and from 6 relatives. Feedback was positive in the care and support offered to people. Comments received through talking to people and from surveys received included ‘I am happy here’ and ‘I like living at Jonathon House’ Comments made by relatives through surveys included ‘The staff at Jonathon House treat all the people as they would do their own family. They provide all the necessary requisites that give a safe and secure environment.’ 1 requirement and 3 recommendations have been met. There has been 1 requirement made though this visit. What the service does well: People are supported through individual and person centred care planning and staff are provided with comprehensive information in order to meet peoples assessed needs. Jonathan House DS0000026539.V351642.R01.S.doc Version 5.2 Page 6 People are supported well in accessing individual opportunities to lead active and fulfilled lifestyles that are both appropriate and reflect their levels of independence. There is an open atmosphere in the home with staff supporting people to communicate their wishes and preferences. Comments received from relatives through surveys identified areas where the home does well ‘the home tries hard to help people achieve goals and encourages people to ‘stretch’’ and ‘Being there when reassurance is needed about problems’ and ‘Gives the right environment for the development or good life style’ 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. Jonathan House DS0000026539.V351642.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 Jonathan House DS0000026539.V351642.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can be assured that the home will meet their assessed and changing care needs. EVIDENCE: There are currently no vacancies and there been no new people who have moved in to the home for the past two years. The majority of the group have lived together for many years. All 7 of the surveys received from people using the service said they had been asked prior to moving in if they wanted to move to home. They said they were happy living at the home and felt well supported by the staff team. Observation of how staff approach and support people indicated that they were respectful in their interactions and people were relaxed and comfortable in the company of the staff. Care files evidenced that people had been admitted to the home through the care management process and that people’s care was being reviewed by their placing authority and by the home regularly. Care files also contained assessments of their needs carried out by the home. Care plans had comprehensive information for staff to follow so that needs are met consistently and individually. Jonathan House DS0000026539.V351642.R01.S.doc Version 5.2 Page 9 5 surveys received from families said that Jonathon House ‘always’ meets the different needs of their relatives whilst 1 survey said the home ‘usually’ meets their needs. Jonathan House DS0000026539.V351642.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 good. This judgement has been made using available evidence including a visit to this service. People are supported through a person centred approach in the planning of their care. The home involves people in the planning of their care and in making decisions about their lifestyles. People are supported to take risks safely and independently in their daily lives. EVIDENCE: Care plans provided useful and comprehensive information so that staff can help to support people and meet their needs. These included information relating to peoples psychological, emotional and social wellbeing. Information was provided with a “person centred” focus to help people in being involved in their care planning and in making decisions about their preferences. Some people showed their Person Centred Plans which were accessible to them and kept in their rooms. Care plan progress and goals were reviewed and monitored through monthly meetings with individuals keyworker. Care planning is also reviewed formally on a yearly basis. Jonathan House DS0000026539.V351642.R01.S.doc Version 5.2 Page 11 Through talking with people living at the home and staff, and from looking at care records, it was evident that the home follows the practice of empowering people in making decisions about their life and how the home is run. People have been involved in the interviewing process for new staff. This included interviewing the new assistant manager and making decisions about the staff people want to be supported by. People spoken with said they are involved in choosing holidays, planning menus, sorting out group activities, and choosing décor for the house. This is done at a house meeting every two weeks. All 7 surveys returned from people said they make decisions about what they want to do each day, during the evenings and at weekends. People are supported and encouraged to live an independent and fulfilling life and take part in varying activities. This involves helping people to take risks safely in their daily lives. Written risk assessments involving people provided enough information in helping to keep them safe. These indicated known risks; factors contributing to risks and strategies to help reduce risks to make sure activites people are involved with are safe. The returned AQAA stated that the risk assessments now need to be ‘simplified’ so that people can understand them better and that this is one of the home’s plans for improvement. Jonathan House DS0000026539.V351642.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 good. This judgement has been made using available evidence including a visit to this service. People are supported to make choices about their lifestyle and in developing and maintaining their independence. The home offers people the opportunity to take part in social, religious and recreational activities in the local community. EVIDENCE: Through discussion with people it was evident that a lot of different activities are enjoyed. Some people have paid work and several people go to college and the organisation’s day service. The home is supporting 2 people in helping that they get the minimum wage for jobs they have done for several years. During evenings and weekends people said they go to pubs and club visits, and shopping or cinema. Staff support people to travel independently in getting to their planned placements. The home has a minibus if needed. Jonathan House DS0000026539.V351642.R01.S.doc Version 5.2 Page 13 Individual holidays are planned with people making their own choices. The majority of people have been on a successful cruise; a photograph album showed people having an enjoyable time. 2 completed surveys from families said that the home ‘always’ supports people to live the life they choose; comments made included ‘ they have encouraged and helped in following many interests and in some cases have turned a dream into a reality’ and ‘They help people achieve potential and give wide ranging experiences; the practical and emotional support is excellent.’ Care plans showed independence programmes to support individuals with their daily routines and personal development. People explained that everyone has a Lifeskills Day when they have support with cleaning their rooms and doing washing. Everyone also shares the cleaning in the common areas of the house, with individuals having their own job. People use the kitchen to help prepare their lunch and breakfast and are supported to help cook dinner. The expert by experience was told that only immediate family could come and visit and that if people wanted a friend to visit, you had to get permission at the residents meeting. This was followed up with the manager who said that people automatically informed others living at the home if someone had been invited over and that this was done as a matter of respect to other people sharing the home. The manager said that Jonathon House is also used as a weekly venue for social activities for people living at other homes and that there are visitors coming to the home on a regular basis. Two people said they see their families regularly and can use the phone to call them if they want to. It was evident that the home supports people with their relationships and that people dictate how they want to be supported. 4 surveys received from families said that the home ‘always’ helps their relative to keep in touch with them, whilst 2 surveys said this ‘usually’ happens. One family said that the home has helped their relative to use internet access in contacting them. 4 surveys also received from families said that they are ‘always’ kept up to date with important issues affecting their relative. 2 surveys said that they are ‘usually.’ Menus looked at indicated that people are offered varied and nutritious meals. Records indicated that alternatives are offered if the main choice is not wanted. Jonathan House DS0000026539.V351642.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 good. This judgement has been made using available evidence including a visit to this service. People who use the services are supported to lead healthy lifestyles with their healthcare and personal needs being monitored well. Staff show a good awareness of how to treat people with respect. Although people are safe guarded by the home’s medication practices some information needs to be recorded better. EVIDENCE: Healthcare records showed that individuals’ physical and mental healthcare needs were being met through regular reviews of medication and support from appropriate professionals. Health Action plans includes medication profile, support with personal needs and records of visit to doctor, consultant, dentist, chiropody, and optician. From discussion with staff, and observation of their interaction with people, it was evident that peoples are treated respectfully and listened to. The home knows when to make referrals to specialist services so that people can be supported in different areas. Jonathan House DS0000026539.V351642.R01.S.doc Version 5.2 Page 15 4 surveys received from families said that the home ‘always’ gives the support or care to their relative that they expect or have agreed with while 2 surveys said that the home ‘usually’ does this. A comment from a relative survey also said.’there is always a seamless transition and the high level of support and care is maintained.’ The procedures in place for administration, storage and disposal of medication were looked at. Individual medication profiles included the uses and side effects of each medication administered. Medication had been signed by administering staff. Although staff spoken with were aware of when an ‘as required’ medication needed to be administered to an individual, a written instruction must also be kept. There are 2 people who self medicate; there was an assessment of their ability to self medicate with monitoring systems to help check that they are taking this safely. A recommendation has been met to obtain peoples consent for medication to be administered. All staff are trained in the administration of medication. There are procedures for other trained staff from another home near by to support with this if there are untrained staff on duty. Jonathan House DS0000026539.V351642.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 good. This judgement has been made using available evidence including a visit to this service. People who use the services are supported to express their concerns with robust procedures and processes in place to respond to complaints; people are protected from abuse. EVIDENCE: There have been 5 complaints logged since the last inspection that have been dealt with appropriately. This was shown through records of action taken and outcome. The assistant manager said that it was felt that somethings had been left unresolved in the past such as a complaint made regarding the length of time it was taking to repair the garden wall. This was now in the process of being repaired during this visit. People spoken with knew how to make a complaint or who to talk to if they were unhappy. One person said that if there were problems with each other “If we argue, we sort it out with a member of staff”. 6 of 7 surveys said that staff treat them well and always listen and act on what is said. 1 survey said staff ‘sometimes’ treat them well and ‘sometimes listen and act on what they say. 5 completed surveys received from families said that they knew how to make a complaint about the care provide by the home; 4 surveys said the home ‘always’ responds appropriately if concerns are raised, whilst 1 survey said this happened ‘usually’. Jonathan House DS0000026539.V351642.R01.S.doc Version 5.2 Page 17 The organisation has a policy on the protection of vulnerable adults and appropriate checks are made on all new staff to help ensure the protection of people. All staff are trained in safeguarding awareness when first employed and as part of their induction, and yearly updates are recorded. Care files had comprehensive reactive strategies in place indicating triggers and indicators that helped staff know when people needed support if unhappy. This helps to ensure there is a consistency in supporting individuals with their different behaviours. The organisation operates safe financial systems for supporting people with their finances that helps protects them from financial abuse. Financial risk assessments included assessment of peoples understanding of money and financial management. Jonathan House DS0000026539.V351642.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use services benefit from a clean, homely, and safe environment that meets their needs. EVIDENCE: Jonathan House is in keeping with the local neighbourhood and is close to local amenities including shops, a church, and a cinema and is a short walk from the “Downs” a large common. There are good transport facilities to access both the City of Bristol and surrounding areas. A requirement has been met for risk assessments to be carried out in relation to accessing hot radiators; that if there is a risk of injury to any person or staff then radiators should be covered to help safeguard individuals safety. A tour of the home was had and all the communal areas of the home were seen. These were presented as comfortable and homely. Jonathan House DS0000026539.V351642.R01.S.doc Version 5.2 Page 19 It was evident that the dining area is a popular area that is used by people on a regular basis and that people felt comfortable being there. Time was spent talking with people during the lunch break with several people and staff. The Expert by Experience said they thought Jonathan House was ‘friendly and welcoming’, though not very accessible for people with mobility impairments with the steep stairs. It was evident that people liked where they live and all surveys stated that ‘the home is fresh and clean’. One person said in their returned survey ‘I want the house to always be clean.’ A cleaner is employed during the week to clean the communal areas of the home whilst people are responsible for their own rooms. The overall environment was presented as safe and clean. A staff member is responsible for completing a monthly audit on the premises ensuring it is a safe place to live and work. Jonathan House DS0000026539.V351642.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35, & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service benefit from staff who have a good understanding of their role, and who are a trained, and competent staff team. There are robust recruitment procedures to help to protect people. EVIDENCE: Staff spoken with explained their roles and responsibilities and said they have enough information in helping to know how people should be supported. There were 2 staff on duty and this was also shown on the rota. Staff have asked for a specific handover time to pass on relevant information. This is now happening and staff said it has been helpful. New staff have an induction period that includes completing the Learning Disability Award Framework (LDAF) and are then encouraged to complete a National Vocational Qualification (NVQ). There are 3 staff who have completed a NVQ and with 1 staff in the process. The returned AQAA stated that an area that could be improved was specified time for staff to complete work assignments for both LDAF and NVQ. The organisation monitors staff training and informs the home of updates needed. Specific senior staff in the organisation have delegated training Jonathan House DS0000026539.V351642.R01.S.doc Version 5.2 Page 21 responsibilities and lead and deliver training in manual handling, safe guarding and challenging behaviour. The assistant manager said that some training has not occurred due to filling of vacancies but that now all booked staff training was a priority. Training attended and updates booked for the near future includes manual handling, fire, first aid, food hygiene and mental capacity act. Staff also use relevant training provided by Social Services. Staffing files seen showed relevant information was in place to show that new staff had been through a clear recruitment process to help ensure the safety and protection of people being supported. Files also contained induction checklists, probationary period assessments, and individual learning plans. Staff are informed of changes and have discussion at regular staff meetings. Staff supervision is shared between the manager and assistant manager. Yearly appraisals are completed to help staff in meeting their goals and monitoring their personal development. Those staff spoken with said that they receive regular supervision. 5 surveys received from families said that they thought staff usually have the right skills and experience to look after people properly, whilst 1 survey said staff ‘always’ have the skills. Comments received from relatives through surveys received included ‘there seems to be a continual change of personnel ‘ and ‘the home can improve with ‘continuity of staff’. Jonathan House DS0000026539.V351642.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): 38, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service benefit from an ‘open’ management approach with systems in place that safeguard and protect the health and safety of those living and working at the home. EVIDENCE: The new registered manager Ms Cowap was unavailable; however the new assistant manager helped with the inspection process. Ms Macgregor has many years of experience in working with people with a learning disability and is in the process of completing a National Vocational Qualification. Staff spoken with were happy with the new management of the home, that they were approachable, listened to and that positive changes have taken place. An area that they felt could improve was better communication. Jonathan House DS0000026539.V351642.R01.S.doc Version 5.2 Page 23 The assistant manager said the home has good relationships with families and receives feedback through the reviewing process and that they are positive; this was also shown through feedback from surveys with families satisfied with the overall care of their relative. People’s views are gained through various ways; house meetings and informal discussions, reviews of their care and questionnaires sent out from the organisation. Records seen relating to the running of the home were satisfactorily written, up to date, and effectively maintained. Staff are responsible for monitoring different areas of the home such as health and safety, fire and medication. A weekly health and safety check is done and requests for any maintenance are sent to the head office. The home notifies us of any information regarding changes affecting peoples’ welfare. The home receives monthly visits from senior managers who monitor people’s care, and health and safety Staff from the organisational personnel department also visit quarterly to check on staffing files and financial procedures. Jonathan House DS0000026539.V351642.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 3 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x x 3 3 x x 3 x Jonathan House DS0000026539.V351642.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. 1. Standard YA20 Regulation 13(2) Requirement Keep written instruction of when ‘as required’ medication is administered. Timescale for action 29/11/07 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 Jonathan House DS0000026539.V351642.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Jonathan House DS0000026539.V351642.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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