Care Home: La Rosa

What the care home does well The home is comfortable, clean, safe and homely and people have single bedrooms and communal areas that suit their needs. The registered manager is qualified and experienced. He demonstrates good leadership and residents, staff and external professionals find him easy to communicate with. A resident commented, "Staff communicate and interact well" and "I asked the manager if I could move into this home because I did not like where I was. I knew it was a better place".La RosaDS0000065081.V376955.R01.S.docVersion 5.2Residents are able to maintain friendships and relationships whilst living in the home and there are a variety of activities available at home and in the community. Residents have a good diet and are able to develop their shopping and cooking skills whilst in the home. Cultural needs are considered and steps are taken to include menu choices for all residents. Personal and health care needs are understood and met and the staff communicate well with associated health teams that are involved in the healthcare of the residents. The manager listens to concerns and complaints and takes appropriate action to improve the service for the residents. Staff are well trained. What has improved since the last inspection? Recruitment procedures are more rigorous and there is evidence that all checks are made before staff start work in the home. This means that residents are better protected. The home manager has worked on a development plan for the home. This means that staff are working on improving t5he service in a planned way. There is also a better plan for keeping staff up to date with training. The written plans about how each resident is to be supported and cared for are written in a better way, with planer English. This means that they are more accessible to the residents. Key inspection report CARE HOME ADULTS 18-65 La Rosa 97 Babington Road Streatham London SW16 6AN Lead Inspector Sonia McKay Key Unannounced Inspection 13th August 2009 08:45 La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service La Rosa Address 97 Babington Road Streatham London SW16 6AN 020 7787 9694 020 8835 0981 vadee.larosa@yahoo.co.uk 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) Mrs Parvadee Shumoogam Gopalakrishnen Naidoo Nursigadoo Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 7 28th August 2008 Date of last inspection Brief Description of the Service: La Rosa is a private residential care home that provides 24-hour care and support for seven adults with mental health needs. The home is situated in a residential area, close to high-street shopping and transport links. The home opened in September 2005. Fees range between £550.00 and £900.00 per week and vary according to the support needs of the individual. The home provides prospective residents with a written guide that provides information about the service. A copy of the most recent Commission inspection report is available in the reception hallway. La Rosa DS0000065081.V376955.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 Stars. This means the people who use this service experience excellent quality outcomes. One inspector carried out this unannounced key inspection in one day. The methods used to assess the quality of service being provided include: • • • • • • • • • • • • Talking with the registered home manager Looking at the Annual Quality Assurance Audit document completed by the manager (this document is sometimes called an AQAA and it provides the Commission with information about the service) Talking to staff on duty during the inspection Talking to four of the seven residents A tour of the communal areas of the premises Looking at records about the care provided to three of the residents Looking at records relating to recent staff recruitment and training Looking at the way medicines are handled by staff in the home Looking at issues that the Commission has been notified about since the last inspection and how they were handled Sending surveys to residents and staff Six residents and four members of staff completed surveys Talking with a visiting health professional The Commission would like to thank all who kindly contributed their time, views and experiences to this inspection process. What the service does well: The home is comfortable, clean, safe and homely and people have single bedrooms and communal areas that suit their needs. The registered manager is qualified and experienced. He demonstrates good leadership and residents, staff and external professionals find him easy to communicate with. A resident commented, “Staff communicate and interact well and I asked the manager if I could move into this home because I did not like where I was. I knew it was a better place. La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 6 Residents are able to maintain friendships and relationships whilst living in the home and there are a variety of activities available at home and in the community. Residents have a good diet and are able to develop their shopping and cooking skills whilst in the home. Cultural needs are considered and steps are taken to include menu choices for all residents. Personal and health care needs are understood and met and the staff communicate well with associated health teams that are involved in the healthcare of the residents. The manager listens to concerns and complaints and takes appropriate action to improve the service for the residents. Staff are well trained. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. La Rosa DS0000065081.V376955.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 La Rosa DS0000065081.V376955.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 & 5. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents can be assured that their needs will be assessed properly before they are offered a place in the home. This means that the home is less likely to admit someone whose needs they are unable to meet. Prospective residents can visit before they decide to move in and they have a signed contract outlining the main terms and conditions of their stay. EVIDENCE: I looked at the information obtained prior to and during the resettlement of one of the residents. He had moved to the home in April 2009. There is a detailed assessment of his health and social care needs on file. This assessment was completed by the home manager before the resident was offered a place in the home. The assessment covers all key areas and also information that will help staff to identify and mental health relapse indicators. The manager obtained reports from a hospital also. Prospective residents are offered an opportunity to visit the home before they move in for an eight week trial period. They are issued with a contract and a signed copy is kept on file. La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Resident can be assured that their care needs and goals are reflected in the written plans. The plans are more accessible and this makes it easier for residents to understand and contribute their ideas to the planning process. There are regular opportunities for residents to discuss their plans and goals and risks are assessed in a way that encourages skills development and greater independence. EVIDENCE: The staff maintain folders of written information about the care and support needs of each resident. We looked at the written plans for two of the current residents. Care planning information is reviewed regularly and a key worker system is in operation. This La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 10 means that each resident has a member of staff to meet with and discuss things with. The key worker has responsibility for keeping the care plans up to date by having regular monthly meetings with the resident. This is an opportunity for the resident to discuss their plans, progress, new issues and any problems they may be having. Records are kept of issues raised and decisions made and pans updated as necessary. As recommended in the previous inspection report, the language used in the plans is now plain English, with less nursing terminology. This means that the information is more accessible to the people that the plans are about. The plans cover a range of topics appropriate to the care and support needs of each resident, although a standard set of areas are also addressed. The plans are more centred on the person themselves and there is a place for residents to add their signature and comments. The information in the plans is clear and concise and they provide staff and residents with practical advice and clear objectives. Key workers review each plan regularly and changes are made when needs change. Risk is assessed in a similar way. Risk assessments cover a range of standard areas, and if a particular risk is identified a specific management plan is put in place. Assessment is used in a way that encourages rehabilitation and skills development, for example opportunities for cooking, shopping and maintaining their own medication. The home manager that residents may need more help from staff when they are unwell and this is factored into the risk assessment. Confidential written information is stored securely in the staff office or a locked filing cabinet. Residents can also keep copies of their plans if they wish. La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 11 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): This is what people staying in this care home experience: 11, 12, 13, 14, 15, 16 & 17. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can maintain the lifestyle of their choosing whilst living in the home and there is support for residents to socialise and go out. Residents can choose their meals and they have an opportunity to develop cooking skills. Cultural needs are well met. EVIDENCE: The residents engage in a variety of daytime activities, and mostly do so without support from staff. Residents are able to maintain friendships and relationships whilst living in the home. They can have visitors and make phone calls. La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 12 Current residents attend a variety of day services suitable to their individual or cultural needs. The resident population is culturally diverse, as is the staff group and local community. There is a payphone for residents to use and people open their own post, but can request staff support to keep letters and documents safely stored. The staff arrange some activities with the residents as a group. There are regular trips to the cinema, day trips and barbeques, birthday parties and bingo nights. There are also regular movie and popcorn nights for those interested. There is a television, DVD player and music system in the communal lounge/diner. The back garden wit patio area and seating. Residents are consulted about the choice of activities provided in regular house meetings. Emphasis is placed helping new residents to get to know the local area. This involves a member of staff going out with all new residents to familiarise them with the local area, transport links, shops and leisure facilities. All residents are registered on the electoral role and staff assist residents to obtain a freedom bus pass if appropriate. There is a four-week rolling menu programme available and records are kept of all meals served. The records show that a range of meals have been prepared, including culturally appropriate dishes. Residents who wish to cook something other than what is on the menu can do so. Some residents are preparing for moving to more independence by becoming more self-catering whilst living in the home. Each resident completes household chores to the best of their abilities. These include responsibilities for the care of their own bedrooms and the communal areas of the home. Responsibilities for the cleaning the communal areas are discussed and agreed in house meetings. There is a petty cash system in place. This enables staff to re-coup any costs incurred whilst supporting residents to take part in community-based activities and for paying for some activities for the residents as well (such as some of the cinema trips). Staff maintain a record of the activities that each resident has taken part in as part of the daily recordings. La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive the support they need to maintain their personal care and their healthcare needs are monitored well. Medication is handled safely and residents have an opportnity to self medicate if they are able. EVIDENCE: Staff can provide assistance with personal care tasks if needed, but generally support residents by verbal prompting and advice. There are both male and female staff available if assistance with personal care is required. If assistance is required, this is detailed in a specific care plan. Residents can get up a go to bed at times of their choosing and staff encourage people to be independent and use their own alarm clocks to wake them up for appointments. La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 14 When a new resident moves in there is a ‘community attachment plan’. This plan identifies healthcare needs and ensures that new residents register with appropriate local health services. These plans are effective. Residents attend appointments by themselves if they wish, although staff can provide support and assistance to keep records and dates of appointments as required. Residents attend appointments with either the community mental health teams (CMHT) or psychiatric teams attached to their placing authority. All are registered with a dentist, optician and chiropodist. The home makes referrals to health teams as required and a visiting health professional gave good feedback about the staff support around her clients healthcare needs. Residents are weighed regularly and the weight is recorded. This assists staff in identifying possible health problems. Staff assist residents to manage their medication and there is appropriate lockable storage for medications in an office. Residents can also administer their own medication if assessed as being safe to do so. Residents have a lockable cabinet in their bedrooms so that they can store medications themselves if required. Two residents are self medicating at the time of this inspection. All prescribed medications are in stock and there are no controlled drugs in storage or use, although appropriate storage is available should any be prescribed. A spot check of medication administration records and medication stocks showed that medications are being administered correctly and staff are keeping good records. There are monthly audits that show the manager how well medications are being handled. Staff receive training in safe administration of medicines. A record is also kept of any medication administered outside the home, for example depot injections administered at clinics. There is information about common side effects of each drug in use. There is a small stock of common home remedies, such as a cough syrup and analgesic, should residents have a minor cough or headache. La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be assured that their concerns and complaints will be listened to and acted upon and the home keeps good records about what they have done to investigate any complaint. Staff know what to do if they suspect abuse and the policies and procedures have been revised to provide better protection from financial abuse. EVIDENCE: There is a complaints procedure in place. The record of complaints and the AQAA (Annual Quality Assurance Assessment) show that there have been three minor complaints made by residents. Appropriate action was taken to address the issues raised and good records are kept of how each complaint was investigated and addressed. There are also regular opportunities for residents to discuss concerns during regular key work and house meetings and for staff to take action. Procedures are in place for responding to suspicion or evidence of abuse or neglect (including whistle-blowing) to ensure the safety and protection of residents. A copy of the local authority ‘safeguarding adults procedure’ is available for reference and staff have been trained in adult protection. La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 16 A spot check on resident’s money held in safe keeping with staff show that satisfactory arrangements are in place for assisting residents to safely store and account for their personal expenditure. As recommended in the previous inspection report, there is now a specific policy prohibiting staff from accepting cash or gifts from residents. This provides residents with better protection from abuse. The policy in regards to the management of service users finances has also been revised to make it safer. La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 & 30. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is comfortable, clean, safe and homely and people have single bedrooms and communal areas that suit their needs. EVIDENCE: The large home is clean, comfortably furnished and well decorated. All bedrooms are single occupancy. The ground floor has a small staff office, a small kitchen, and a dining/sitting room with access to a back garden. Since changes in legislation about smoking in communal settings, residents are asked to smoke in the garden and not in the communal lounge diner. There are adequate toilet facilities and a small ground floor laundry area. La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 18 The ground floor has one bedroom. The first floor has four bedrooms, three with en-suite facilities. There is also a bathroom. The second floor has two bedrooms, both with en-suite facilities and there is an additional bathroom with a shower unit. There is also a staff room. Residents said that bedrooms are comfortable and warm enough. Bathrooms and toilets are fitted with appropriate privacy locks and hot water is regulated to within safe temperature limits and tested regularly. The safety of unguarded radiators and hot central heating pipes is assessed if any resident who experiences falls, epileptic seizures or absences of any sort is admitted to the home, as recommended in the previous inspection report. There is good access to local transport links and high street shopping. There is a payphone available. La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff team are competent and qualified and there are enough staff on duty. Recruitment checks are rigorous and this protects the vulnerable residents. Staff are supervised often and there is a good training programme to keep them up to date. EVIDENCE: There is a registered manager, deputy home manager (post currently vacant) and seven support workers. There are currently six male and one female residents. There are male and female staff and the team is ethnically diverse, as is the resident group and local population. Of the eight staff employed, six have attained a vocational qualification in care at NVQ level 2 or above. There is also a training programme around specific issues such as safeguarding, risk assessment, person centred planning and mandatory training such as First Aid and Food hygiene. La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 20 The home manager has a training background and he is able to brief his team on changes in legislation, for example, providing a brief and leaflets about the new deprivation of Liberty Safeguards. There are two staff on duty during the day and one member of staff is awake on premises each night. A lone working risk assessment is in place for each resident. Seven of the nine staff have already completed a national vocational qualification (NVQ at level 2 or above) in care and the two remaining staff are currently undertaking the award. I checked the records relating to the recruitment of a member of staff who had recently joined the team. All required documents are in place and there is evidence that all necessary checks were undertaken before the member of staff started work in the home. There is induction training in their probationary period. As required in the previous inspection report, there is a team training and development plan in place. As the deputy manager post is currently vacant, the home manager is supervising the whole team. Staff meet with the manager on a regular basis and there is a record of each meeting. Each member of staff has a personal development plan in place. La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41 & 42. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is experienced and qualified and he demonstrated effective leadership of the service. He has clear plans for how the service can be improved and he is keeping himself and the team up to date with current changes in legislation. Systems are in place to ensure environmental health and safety. Quality Assurance monitoring is improving. The Commission must be notified of any significant events, such as injuries, sustained in the home. EVIDENCE: The registered manager is qualified and has many years experience of senior management and mental health nursing care. He has been registered with the Commission. He has familiarised himself with the National Minimum Standards La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 22 and Care Homes Regulations and this has informed his leadership of the home. The AQAA (Annual Quality assurance Audit) he completed is detailed and provides us with good information and examples of how the service is running in the best interests of the residents. There is positive feedback about his management and leadership from residents, staff and external professionals. There are regular residents meetings and residents also join in part of the staff meetings to discuss house issues. The home manager also meets with each resident to discuss how they are and get feedback about the service provided. The quality assurance system has improved and surveys are sent to residents regularly. The feedback is used to improve the service and it is documented. The registered provider visits the service each month to conduct an inspection visit in accordance with Regulation 26. Brief reports of the findings of these visits are available in the home. As recommended in the previous inspection report, there is an annual development plan for the home. A health and safety and fire risk assessment are in place and have been reviewed regularly. Accidents and incidents are recorded and there is a daily record of the care provided to each resident. Fire evacuation procedures and a building floor plan are displayed. Fire detection equipment is tested each week, and the fire fighting and detection equipment is also professionally tested on a regular basis. La Rosa DS0000065081.V376955.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 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 X 4 3 5 3 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 4 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 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 3 LIFESTYLES Standard No Score 11 3 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 4 3 3 X 3 3 X Version 5.2 Page 24 La Rosa DS0000065081.V376955.R01.S.doc No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations La Rosa DS0000065081.V376955.R01.S.doc Version 5.2 Page 25 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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