Care Home: Loddon House

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What the care home does well The homes uses pictures and photographs and try to make sure that people can understand anything that they might need to know. Staff look at what people need quite often, to make sure that they carry on helping them in the best way. The staff help people to choose as much for themselves as they can. Residents have what is called a `circle of support`. That is, all the people who are involved with the residents are invited to meetings to help make sure that they are helped to have an enjoyable life, in the best way possible. People have quite a lot of things to do so that they do not get fed up or bored.People are given their medicine in a very safe way and make sure that everyone takes it properly so that they can stay as healthy as possible. The home makes sure that people are as safe as possible and can say if they are not happy. The home has plenty of staff so that everyone gets enough help. What has improved since the last inspection? The home makes sure that all the risk assessments are looked at often, so that they are up-to-date and people are safe. The home has a good way of writing down what residents need so that staff can help them in the best way. The home has good ways of making sure that everybody goes to the Doctor or nurse when they need to so that they stay healthy. The furniture and floors in the home are nice and clean. The home has plenty of ways of making sure that they try to make things better for the people who live there. What the care home could do better: The home could make sure that all the residents have a key worker to look after all their needs, or two key workers if this is better for them. The home could look at the gates where people come into the garden and see if they can make them look more friendly so that visitors feel welcome. The manager must be `registered` with the Commission for Social Care Inspection so that they can say that he is `safe` to be in charge of the home. CARE HOME ADULTS 18-65 Loddon House Loddon Court Farm, Beech Hill Rd Spencers Wood Nr Reading Berkshire RG7 1HT Lead Inspector Kerry Kingston Unannounced Inspection 11:15 8th January 2008 DS0000011378.V355840.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 DS0000011378.V355840.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. DS0000011378.V355840.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Loddon House Address Loddon Court Farm, Beech Hill Rd Spencers Wood Nr Reading Berkshire RG7 1HT 0118 988 4647 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) cosen.sayi@new-support.org.uk www.dimensions-uk.org New Support Options Ltd Vacant Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places DS0000011378.V355840.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 2007 Brief Description of the Service: Loddon House is a residential care home offering twenty-four hour care to four adults who have learning and associated behavioural difficulties. The home is a two-storey building and is not able to provide a service to people with severe physical disabilities, as there is no lift access to the first floor. The home has six single bedrooms, two are on the ground floor, they all have wash- basins but do not have en-suite facilities. The home is situated in a quiet residential area close to the village centre. There are local facilities within walking distance of the home. The home has two vehicles and the people who use the service are able to access public transport, as appropriate. Current charge per person is £1,825.00 per week. People who use the service pay extra for some outings, toiletries and personal shopping. DS0000011378.V355840.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 2 stars. This means that the people who use the service experience good outcomes. This is a report for the key inspection of the service, which included a routine unannounced site visit. This took place between the hours of 11.15 am and 5.30 pm on the 8th January 2008. The information was collected from the Annual Quality Assurance Assessment, a document sent to the service by the Commission for Social care Inspection and completed by the manager of the service. There are, currently, four people resident in the home, there are no plans to admit any other residents because of the diverse needs of the current resident group. Discussions with two staff members and the deputy Manager took place. The people who use the service have no or limited verbal skills, therefore observation was used as a source of information throughout the visit. A tour of the home and reviewing residents’ and other records were also used to collect information on the day of the visit. The home has complied with all the requirements made at the last inspection and has met the recommendations. What the service does well: The homes uses pictures and photographs and try to make sure that people can understand anything that they might need to know. Staff look at what people need quite often, to make sure that they carry on helping them in the best way. The staff help people to choose as much for themselves as they can. Residents have what is called a ‘circle of support’. That is, all the people who are involved with the residents are invited to meetings to help make sure that they are helped to have an enjoyable life, in the best way possible. People have quite a lot of things to do so that they do not get fed up or bored. DS0000011378.V355840.R01.S.doc Version 5.2 Page 6 People are given their medicine in a very safe way and make sure that everyone takes it properly so that they can stay as healthy as possible. The home makes sure that people are as safe as possible and can say if they are not happy. The home has plenty of staff so that everyone gets enough help. 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. DS0000011378.V355840.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 DS0000011378.V355840.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. People who use the service experience good quality outcomes in this area. The home would properly assess any prospective residents and ensure that they could meet their needs. The home has up-to-date information about the service that is available to prospective residents so that they could make a choice about where to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who use the service are given information about the home in the Service User Guide, which is provided in the necessary format to meet their needs and abilities. Copies of information given are kept in the individuals care files, this has been recently up-dated. There have been no new admissions since the last inspection, the current group of people have been resident in the home since 1993. The home has carefully considered the diversity and equality needs of the current service group and it has been agreed that it may be difficult to meet each individuals’ complex needs if another resident were admitted to the home. DS0000011378.V355840.R01.S.doc Version 5.2 Page 9 The home has robust assessment processes and procedures and would fully assess peoples’ needs prior to admission. DS0000011378.V355840.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 and 9. People who use the service experience good quality outcomes in this area. Residents care plans are changed often, to ensure that their changing needs are met. Risk assessments are reviewed on a regular basis according to the needs of the people who use the service so that they can stay as active and independent as possible for as long as possible. Residents are encouraged to make as many decisions about their life as they are able. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans for three residents were seen. These include vital information sheets, which note all the information that is important to the individual such as contacts, benefits, wishes, preferences and what people want to happen in event of their long-term illness or death, including, whether they have a will or funeral plan. Vital information sheets are reviewed with the rest of the care plans, four to five monthly or when something changes. DS0000011378.V355840.R01.S.doc Version 5.2 Page 11 Individual care plans clearly note peoples’ needs with regard to any equality and diversity issues, such as specific physical needs, age and any religious or cultural beliefs. The home has contacted a Swedish church to try to determine if a resident has a Swedish background (his passport was found to be Swedish when it was discovered.) Care plans also note sexuality such as sexual preferences and whether people are sexually active or not and religion and how people deal with it such as ‘no active church attendance but enjoys celebrating special religious occasions, but not in church’. The last care plan reviews were held between September and December 2007. Each individual has a ‘circle of support meeting’ as well as a formal annual review. The circle of support meeting includes all those people who are interested and involved in the care of the individual (they attend with residents’ agreement). It will become the formal review meeting as the person centred planning procedures develop. Circle of support meetings look at needs, changes needed to meet the needs and produces an ‘action’ plan for each person. Notes of the meeting are presented in pictures and symbols, so that residents are given every opportunity to understand what is written about them and what it means. The action plans are ‘ticked’ when actions have been taken. The care plan also incorporates a support needs plan that includes the method of communication, advocacy, physical needs, comprehension, medication, general health plan, sleep pattern, night time needs, dietary needs, emotional health, expressing distress, personal care, social/leisure and daily living skills. People are helped to make as many decisions as possible and the care plans include descriptions of how people express their opinions if they are unable to verbally communicate clearly. One person agreed that he could ‘choose what he wanted to do’. Additional staffing has been obtained so that people can attend a Friday night social club on a regular basis. Risk assessments are detailed and support people with daily living tasks, social and leisure activities and whatever else is appropriate. Guidelines for activities reflect the risk assessments, such as bathing and aggressive behaviours. Risk assessments are reviewed regularly most were last reviewed in November 2007. Development work is continuing to enhance the standard of care plans for the people who use the service that is, one person has a fully completed person centred plan presented in the new staff and resident friendly format and the other two are being completed. DS0000011378.V355840.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): 12,13,15,16 and 17. People who use the service experience good quality outcomes in this area. The home helps people to have an interesting and rewarding lifestyle. It helps them keep in contact with family and friends or advocates and supporters, if there is no family contact. People who use the service are provided with good food, to their own choice and preference. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Activity plans for three people who use the service were seen. The resident group is relatively elderly (59 to 78) and the activity plans reflect age and interests with regard to making choices about what they want to do and when, often they prefer not to participate in activities offered. Two staff said that they felt that people had enough activities to do and one is trying to develop some more diverse activities so that people have more choice. All residents have some external day services provided by the local authority, DS0000011378.V355840.R01.S.doc Version 5.2 Page 13 one to three sessions a week. Staff support people to access the local community, which includes, walks, drives, pub visits and shopping trips. One staff member felt that activities could be improved and the home is developing a plan where everyone has a ‘meaningful’ activity every morning and afternoon. One person went on holiday in 2007, one holiday had to be cancelled due to lack of staffing, he has not had a holiday since 2005 and one person prefers day trips to holidays. The home has two vehicles to support the residents to access activities. One person makes poppies and staff encourage him in this pursuit, which is very important to him. On the day of the visit all of the residents went out at some time during the day, these included one person having lunch out, a trip to the garden centre and a walk in the community. Staff were seen to respond immediately and appropriately to people who expressed a desire to do an activity. Residents are helped to maintain any family contacts but two people do not have families, all residents have an advocate and a ‘circle of support’ (people who are involved or have an interest in the care of the individual). One resident agreed that it ‘is a good place to live’ and that he ‘likes living there. Staff were seen encouraging people to help with meal preparation and daily activities. The menu was varied and residents were seen to have choice and make decisions for themselves during the mealtime such as what sauces to have and how and where to eat their meal. Residents care plans noted whether people had any nutritional needs or requirements and included weight charts, as necessary. DS0000011378.V355840.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 and 20. People who use the service experience good quality outcomes in this area. The home meets peoples’ personal, emotional and health care needs so that they can stay as healthy and happy as possible. The home has very robust medication administration procedures to ensure that all medicines are safely and properly given. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were looked at, they are detailed and include peoples’ choices and preferences and how they express them. They include personal care support plans, which are supported by risk assessments and guidelines. Staff were observed to be following guidelines and treating people with respect and sensitivity, during the visit. Each resident has their healthcare and emotional needs identified in their care plans, a healthcare plan is developed from the care plan and a ‘health booklet’ is produced for each individual. The booklet, can be completed by health professionals, when a resident goes for a consultation and another part of the booklet can be taken by an individual to appointments or during hospital stays so that people are able to better understand their individual needs. DS0000011378.V355840.R01.S.doc Version 5.2 Page 15 The home also has health appointment records and an annual health appointment summary sheet (although this had not been fully completed for all residents for 2007). All residents have received appropriate health checks such as chiropody, dental and opticians and specialist support is sought as necessary, one person has regular psychiatry appointments. The home uses a monitored dosage system for the administration of medication. There have been no medication errors recorded or reported since the last inspection, the deputy confirmed that there had not been any. Staff are assessed prior to administering medication, this takes the form of senior staff observing their practice and the completion of a written assessment pack. All staffs’ competence to administer medication is reassessed six monthly. Two staff administer all medication. The medication files include photographs of the residents, guidelines of when to administer medication prescribed to be taken, when necessary and a description of how individuals’ express pain and distress. Two people have medication to help control their behaviour and the home has appropriate guidelines in place for when to administer. A discussion about the G.P taking responsibility to sign the guidelines that staff use, took place and the deputy manager agreed to look at this issue. Incidents reports are completed whenever medication is administered to help to support a resident to control their behaviour. DS0000011378.V355840.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 and 23. People who use the service experience good quality outcomes in this area. The home listens to the people who live there and keeps people safe from all forms of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The deputy manager confirmed that there had been no concerns or complaints about the home since the last inspection. Any concerns that residents have are responded to on a daily basis (such as people entering each others bedrooms) and appropriate action is taken, for instance a special lock has been provided to protect an individual and his property. These actions are recorded in daily notes and are discussed at the ‘circle of Support’ meetings’ where action plans are developed. They can then be transferred to the home’s ‘PATH’, a development plan for the home that is monitored three, six and twelve monthly. The ‘PATH’ tracks developments and ensures actions are taken, as agreed, in response to staff or residents’ concerns. The complaints procedure is produced in a pictorial and symbol format, it is unlikely that residents would be able to make a formal complaint without the support of the staff team, but the presentation of the information gives people as much opportunity as possible to understand the process. Two staff described how they know if someone is unhappy and how they attempt to interpret their distressed or ‘out of the ordinary’ behaviour. The home has a vulnerability analysis in place for several areas such as finance, vulnerability to physical abuse and emotional abuse. These are supported by risk assessments and guidelines, where necessary, and are a DS0000011378.V355840.R01.S.doc Version 5.2 Page 17 method of meeting peoples’ needs where they are very diverse, such as, some displaying aggressive behaviour on occasion and others being vulnerable to this behaviour. Residents were observed to be relaxed and comfortable in the presence of staff and staff were responding to them positively. The home uses the multi agency safeguarding policies and procedures and the two staff spoken to were able to clearly explain what they would do if they suspected abuse or poor practice within the home. The home took appropriate action when an incident arose that was potentially dangerous for residents. The Commission for Social Care Inspection has received no information with regard to complaints about this service, one Safeguarding referral has been by made by the home (the Commission were made aware of the referral by the service). One resident’s finances are dealt with by the Court of Protection, one has an Age Concern advocate and one has an appointee from within the provider organisation. Financial records of two residents were seen and were accurate, with receipts for all withdrawals. Some advice was given with regard to having two signatures on significant withdrawals. DS0000011378.V355840.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 and 30. People who use the service experience good quality outcomes in this area. The home is suitable to meet the needs of the people who live there. The home is kept clean and there are no hygiene issues. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the home was completed. All areas were seen to be clean and tidy and new flooring had been laid in the entire ground floor. The furniture in communal areas was of an adequate standard and the deputy outlined some plans for creating a more homely environment. The toilets and bathrooms were clean and there were no offensive odours. Residents’ bedrooms were well furnished and reflected peoples’ choices and personality. Equipment in the downstairs bathroom reflected the physical needs of one of the residents and the special lock fitted to his bedroom door acknowledged his diversity and equality needs. DS0000011378.V355840.R01.S.doc Version 5.2 Page 19 There was a discussion about the ‘unwelcoming’ look of the secure gates at the entrance to the home, the deputy manager agreed that they would think about how they could be made to look less ‘austere and institutional’. DS0000011378.V355840.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. People who use the service experience good quality outcomes in this area. The staff team are effective and the recruitment processes ensure their safety. Staff are properly qualified, there are a large amount of staff who work less than thirty-seven hours per week but the home is developing ways to ensure that the people who live in the home receive consistent care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a minimum of three staff per shift, during daytime hours and one waking night person supported by someone sleeping in. The staffing ratio is high to meet the diverse needs of the resident group. Three of the twelve staff are full time and there are several staff who work thirty hours per week. The home uses various methods to ensure that communication between staff is good, to minimise any lack of continuity that could occur, such as monthly staff meetings, a communication book, diary and a one hour handover period. Staff said that they did not feel there was a continuity problem but there was an issue about part time staff being able to take full responsibility for the ‘key worker’ role. The deputy manager said that the home is currently working on this area and hope to develop a co-key working system. DS0000011378.V355840.R01.S.doc Version 5.2 Page 21 Head office is responsible for the recruitment and employment of staff for the home. All original copies of employment records are held there and the home is supplied with copies of the key information such as application form, passport and visa, photograph, references and criminal records check. Two employees information was reviewed and both had the required information. The newest staff members’ paperwork had not been received by the home but personnel confirmed that it had been posted, the deputy manager confirmed that CRB checks and disclosures are seen by herself or the manager prior to appointment. Five of the twelve staff have or have nearly completed their NVQ 2 or above. Training records showed that staff have opportunities to participate in various training programmes and ‘Skills for Care’ completed a training profile for all individual staff in June of 2007. The staff and deputy manager confirmed that they have received mandatory training and up-dates or it is planned but training records need up dating to accurately reflect all staffs’ training. Staff said that they have good training opportunities and feel supported by the senior team, they have regular supervision. The issues identified by staff as a problem with so many people working part time hours were opportunities for supervision, attending staff meetings and fulfilling key worker responsibilities. Staff were observed to be working in a sensitive, respectful and positive way with the people who live there. DS0000011378.V355840.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. People who use the service experience good quality outcomes in this area. The home is properly managed by a senior team, which includes a capable and committed deputy manager. The manager has not applied for registration by the Commission. The home is run in the best interests of the residents, who are kept as safely as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The previous registered manager resigned in February 2007. The new manager has been in post for several months but has not applied to the Commission to be the registered manager of the service. The deputy manager was available throughout the site visit, she was very knowledgeable, committed to the people who live there and is involved in a DS0000011378.V355840.R01.S.doc Version 5.2 Page 23 great deal of development work such as person centred planning, with the aim of improving outcomes for the residents. The home has Quality Assurance systems that include regular Regulation 26 visits, consultations with residents via questionnaires (with key worker support), staff questionnaires and person centred plan audits. The home does not seek the views of other interested parties directly but they are involved in the ‘circle of support’ meetings that are held to look at residents needs. The organisation has a regional planning day to develop an annual development plan for the organisation and the home has a day to develop the individual PATH (Planning Tomorrow with Hope) for the home (a pictorial plan which sets goals for the short and long term to improve the standard of care and quality of life for the residents). The Annual Quality Assurance Assessment confirmed that all the necessary Health and Safety checks and maintenance routines have been completed and all the necessary Health and Safety Policies and procedures are in place. The home has accident and incident forms which are completed in detail. They could be improved to include how the home will minimise the risk of such incidents recurring. The incident forms cross-reference with the administration of medication prescribed to help people to control their behaviour. Health and Safety, including incident and accident forms are audited by the provider organisation and the home has access to a designated Health and Safety Officer, if necessary. DS0000011378.V355840.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 X 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 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X DS0000011378.V355840.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 YA37 Regulation Requirement Timescale for action 01/03/08 11 (C.S.A. To apply for registration by the 2000) Commission to ensure that the manager is suitably qualified and experienced to run the service in the best interests of the people who live there and is not committing an offence by running the home whilst unregistered. 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. 2. Refer to Standard YA6 YA24 Good Practice Recommendations To ensure that each resident has a key working system to support the needs of the residents. To make the entrance gate more welcoming and less ‘institutional’ looking. DS0000011378.V355840.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 DS0000011378.V355840.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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