Care Home: Parry House

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What the care home does well The home is a nice and comfortable place to live.There is a good and assessment process in place to make sure the home can meet the needs of the people who live there. The care plans tell the staff how to care for the people living in the home.The people who live in the home are good friends. The home makes sure that the people who live in the home are safe when they go out and take part in activities. The home provides good healthy meals for all the people who live there.Staff have good training to help support the people living in the home.DS0000057633.V331569.R01.S.docVersion 5.2Page 7The people who live in the home and their friends and family, are supported to make their views known. What has improved since the last inspection? The home makes sure that staff know how to deal with chemicals. What the care home could do better: This inspection at the home has shown just one thing that needs to be improved. The care plans must fully tell the staff how to care for the people living in the home. CARE HOME ADULTS 18-65 Parry House 15 Huckleberry Close Purley on Thames Berkshire RG8 8EH Lead Inspector Barbara Mulligan Unannounced Inspection 19th April 2007 10:30 DS0000057633.V331569.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 DS0000057633.V331569.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. DS0000057633.V331569.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Parry House Address 15 Huckleberry Close Purley on Thames Berkshire RG8 8EH 0118 942 7608 0118 942 6671 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) Purley Park Trust Limited Mr Andrew Mark Gouldthorpe Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (8), Physical disability (2) of places DS0000057633.V331569.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents with the PD category only to be accommodated in ground floor bedrooms. 12th September 2005 Date of last inspection Brief Description of the Service: Parry House is a two-storey eight-bedded home providing residential and day care support to adults with learning disabilities. Each service user has their own personalised bedroom and six of these on the upper floor have with en-suite shower rooms and toilets. There is an assisted bath on the lower floor that is available to all service users. Parry House is part of Purley Park Trust where there are eight registered Homes, comprising of a variety of accommodation and support facilities. Service users have access to the grounds at Purley Park and Parry house has its own private outdoor area for the use of the people who live in the home. Other facilities available to service users include horticultural therapy, day services, social, recreational and leisure pursuits and the on site club house. Local facilities accessed include shopping facilities and the local village including Church. The home is close to public transport links and has its own transport to facilitate service users social activities. Fees range from £503 per week to £798 per week. DS0000057633.V331569.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was undertaken on Thursday 19th April 2006 at 10:30am. This inspection was conducted over the course of a day and covered all of the key standards for younger adults. Prior to the visit, a questionnaire was sent to the manager alongside comment cards for distribution to service users, relatives and visiting professionals. Any replies have helped to form judgements about the service; overall respondents were satisfied with standards of care and considered that needs are being met by the manager and staff team. The visit consisted of discussion with staff and management, observation of the routines within the home, a tour of the premises and examination of some of the required records was also undertaken. There were opportunities to meet and speak with service users. A key theme of the inspection was assessment of how the home meets needs arising from equality and diversity. The inspection officer was Barbara Mulligan. Twenty-five of the National Minimum Standards were assessed during this visit and these have all been fully met. As a result of the inspection the home has received one recommendation. The evidence seen and documentation observed indicates that this service meets the diverse needs [e.g. religious, racial, cultural, disability] of individuals within the limits of its Statement of Purpose. At the end of the inspection, feedback was given to the manager. The inspector would like to thank the deputy manager, the staff team and service users for their cooperation and assistance during this inspection. What the service does well: The home is a nice and comfortable place to live. DS0000057633.V331569.R01.S.doc Version 5.2 Page 6 There is a good and assessment process in place to make sure the home can meet the needs of the people who live there. The care plans tell the staff how to care for the people living in the home. The people who live in the home are good friends. The home makes sure that the people who live in the home are safe when they go out and take part in activities. The home provides good healthy meals for all the people who live there. Staff have good training to help support the people living in the home. DS0000057633.V331569.R01.S.doc Version 5.2 Page 7 The people who live in the home and their friends and family, are supported to make their views known. What has improved since the last inspection? What they could do better: This inspection at the home has shown just one thing that needs to be improved. The care plans must fully tell the staff how to care for the people living in the home. DS0000057633.V331569.R01.S.doc Version 5.2 Page 8 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. DS0000057633.V331569.R01.S.doc Version 5.2 Page 9 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 DS0000057633.V331569.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good. Potential service users receive a needs assessment undertaken by staff trained to do so, ensuring that the home can meet the care needs requirements of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The last admission to the home was in August 2006. The inspector examined the initial assessment documentation for this individual. This was comprehensive and detailed. The admission tool is fully completed and some areas this covers includes personal details, daily routines and interests, likes and dislikes, personal hygiene needs, special service needs i.e. physiotherapy, occupational therapy. The assessment documentation is signed and dated by the author. The inspector was informed that it is the responsibility of the care and training coordinator or the registered manager for the home. The views of existing service users would be taken into account. DS0000057633.V331569.R01.S.doc Version 5.2 Page 11 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. Quality in this outcome area is good. Care plans have been produced for all service users, but need to be further developed to ensure that all current needs have been identified and documented. Service users are enabled to make decisions and be as independent as possible, providing them with choice and involvement. Service users are being enabled to take responsible risks, ensuring that their independence is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five care plans were examined during this inspection, including those most newly admitted to the home. On the whole the care plans contain basic information to guide care staff in meeting the needs of service users. However, there is a lack of detail in the action plan and these would benefit from further from information that sets out in detail the action to be taken by care staff to ensure the assessed needs of service users cab be fully met. For example one entry in a care plan records DS0000057633.V331569.R01.S.doc Version 5.2 Page 12 under basic care “requires help throughout all these areas”. This is a very vague statement and requires further detail. Another entry records that a service users wears a hearing aid in one ear. However the plan of care does not record which ear the aid worn in and if the individual can put the aid in herself or does she require support to do this. A recommendation has been made to address this. Staff respect service users rights to make decisions and individuals are provided with some assistance and communication support to make decisions about their lives. In discussions held with service users it was confirmed that monthly meetings are held in the home. Those people completing comment cards felt that service users’ needs are being met at the home and that staff enable service users to live the lives they wish to. Risk assessments were observed to be in place and these are signed and dated by the author. Examples of risk assessments seen include accessing the kitchen and using cooking implements, self-harm, falls, using transport and allergies. Missing person procedures were in place in the event of anyone being absent from the home without notice and for staff to refer to, if need be. DS0000057633.V331569.R01.S.doc Version 5.2 Page 13 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. Quality in this outcome area is good. Service users have access to appropriate activities and make use of the local facilities, providing stimulation and variety. Service users are enabled to keep in contact with friends and family, maintaining important social links. The rights of the individual are respected, promoting fulfilment and affording service users respect. Service users are encouraged to develop the menus with support from care staff that should promote independence and choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Records showed that service users’ interests are taken into account when organising activities for them, whether as part of the day service provision or when at home DS0000057633.V331569.R01.S.doc Version 5.2 Page 14 Service users are given opportunities to maintain and develop social, emotional, communication and independent living skills and there is evidence of this in service user plans. Day services provide opportunities for further education and service users also attend the day care activities on site that is organised by three day-care coordinators. Individual day care activity time tables are available for inspection within individual care plans. These show that there is a varied range of day care activities to suit the individuals needs and wishes. Examples seen include college, music therapy, cooking, ladies corner, bowling, reading and craft corner. One relative responding by comment card said “There are a lot of activities provided and a lot of trips organised to places of interest.” There is good use of community resources with adequate staff support to access these resources. Service users are well supported by the home and the organisation in pursuing appropriate activities. Individuals take part in varied leisure activities and use local community facilities regularly. Examples seen include the local leisure centre, cinema, shops, library, health centre and local pubs and restaurants. The inspector was informed that relations with the neighbours were positive and that there had been no problems encountered. Service users have access to transport and use taxis, buses, dial-a-ride and trains and evidence was seen in the care plans and through discussions held with service users. There are two mini buses available on the complex that is the main mode of transport for service users. There are no restrictions about family and friends visiting and this was confirmed during discussions held with service users. Service users are able to receive visitors in the privacy of their own rooms, and are able to choose whom they see and do not see. There are no restrictions on visiting, and this is documented in the Service Users Guide. People completing comment cards confirmed that contact is maintained and that visits and telephone calls are welcomed. Staff were observed knocking on bedroom, toilet and bathroom doors ensuring the privacy of individuals. If service users express a wish to have a key to their own bedrooms then this will be facilitated. Staff open mail with the service users, if they are unable to do so themselves and the mail is read to them. Preferred term of address are used for service users and this is recorded in the care plans. DS0000057633.V331569.R01.S.doc Version 5.2 Page 15 Care staff were seen interacting with service users and did so with respect and in a manner that is appropriate to the individual. The kitchen was well stocked with food with plenty of fresh fruit and vegetables available. Menus were varied and these are chosen by service users with support from care staff, on a weekly basis. One person who completed a comment card felt that the food was “very nice and tasty and there is varied diet”. The inspector had the opportunity to join service users for a lunchtime meal. This was relaxed, unrushed and well organised. All meals seen were attractively presented and alternatives were observed to be provided for two individuals who did not wish for the main meal. Menus are chosen by service users and this is undertaken on a weekly basis. The home offers drinks and snacks throughout the day in accordance with needs of the service users. The nutritional needs of service users are assessed and there is evidence of regular monitoring in all care plans looked at. DS0000057633.V331569.R01.S.doc Version 5.2 Page 16 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. Quality in this outcome area is good. Service users’ needs are outlined within their individual plans, ensuring that the manner in which they are supported and cared for by staff is appropriate and promotes their preferences. Healthcare support for service users is very good and ensures service users health and wellbeing is promoted and protected. Medication procedures within the home are robust and staff training good, which ensures that service users are protected by the systems in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information regarding personal care is recorded in individual care plans. Service users are supported to choose when they like to go to bed, have a bath, have their meals and take part in other activities. It is evident from discussions held with service users that service users are supported to choose their own clothes, hairstyles and make up. There is good evidence of health care screening in service users personal files. DS0000057633.V331569.R01.S.doc Version 5.2 Page 17 Visits to the home from healthcare professionals take place in the service users bedrooms. A GP surgery is held on site weekly and all service users are registered with this practice. Service users have access to all NHS healthcare facilities in the local community. The inspector was informed that several service users attend a local dentist and others attend a practise that offers greater support to people with learning disabilities Staff provide support to individuals needing to attend outpatient and other appointments. There is evidence that eye screening is being undertaken on an annual basis and a domiciliary optical service visits the site regularly. Chiropody Services visit the site regularly and there is evidence of this within the care plans. The home have recently received good support from the Community Psychiatric nurse regarding the needs of one service users who has recently developed dementia. Additional support is accessed via the GP and this includes physiotherapy, Occupational Therapy and a Dietician. None of the service users in the home are able to self-administer their own medication. The home uses a monitored dosage system. All medication is administered with two staff present and both staff sign to record that medication has been administered. This is good practice and is to be commended. There were no out of date medications held in the service users home with a returns procedure in place. The inspector examined medication records and it is pleasing to note there were no omissions observed. Records show all medication received, administered and leaving the home, or disposed of. There are no controlled drugs in use at the time of the visit. If a service user became ill, an assessment would be carried out with the involvement of their family, and the service users wishes regarding terminal care and death would be discussed, and carried out. DS0000057633.V331569.R01.S.doc Version 5.2 Page 18 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. Quality in this outcome area is excellent. The home has effective complaints procedures to ensure that service users or their representatives are listened to. Vulnerable adults are protected through a range of policies and procedures and well informed staff, which means that their intrinsic human rights are protected. POVA training for all care staff is up to date. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has complaints procedures and those responding via comment cards were aware of how to raise any issues or concerns about the service. Copies of the complaints procedure are included in the Statement of Purpose and the Service Users Guide and this gives guidance about referring a complaint to the Commission for Social Care Inspection. The home’s complaints log records three complaints received since the previous inspection. These are well recorded and responded to within the stated timescales. The Commission have not received any complaints about this service. The home uses the West Berkshire Multi Agency POVA policy and an organisational policy in conjunction with this. This includes guidelines for staff about the responsibilities of the staff, types and signs of abuse and what to do if you suspect abuse. All care staff receive training about Adult Abuse and this DS0000057633.V331569.R01.S.doc Version 5.2 Page 19 forms part of their induction. There have not been any allegations of abuse reported to the Commission. The homes policies regarding service users money and financial affairs ensure service users access to their money, valuables and safe storage is safe guarded. Staff are instructed during induction about physical and verbal aggression by a service user. DS0000057633.V331569.R01.S.doc Version 5.2 Page 20 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, 27, 28, 29 and 30. Quality in this outcome area is good. The standard of the environment within this home is good, providing service users with an attractive and homely place to live. The overall quality of the furnishings and fittings is good ensuring the safety and comfort of service users. Standards of cleanliness at the home appear to be good meaning that service users live in an environment that is clean and hygienic, protecting their health, safety and welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Parry House is a two-storey eight-bedded home providing residential and day care support to adults with learning disabilities. The home is part of Purley Park Trust where there are eight registered Homes and a variety of accommodation and support facilities. DS0000057633.V331569.R01.S.doc Version 5.2 Page 21 Each service user has their own personalised bedroom and six of these on the upper floor have with en-suite shower rooms and toilets. There is an assisted bath on the lower floor that is available to all service users. The building has accommodation on two floors, with all single rooms and bright airy communal areas and no unpleasant odours were evident. The lounge and dining areas are nicely decorated and there are personal touches around the home such as flowers, plants, books and pictures. The furnishings observed in communal areas are of good quality and suitable for the range of interests and activities preferred by service users. Lighting in communal areas is domestic in character and sufficient to facilitate reading and other activities. The kitchen is clean and appears to be well looked after. The home has a pleasant wooden decked area outside and service users were enjoying the sun on the day of the visit. There are no CCTV cameras in use within the home at the time of the inspection. Laundry facilities are sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten and do not intrude on service users. The laundry floor finishes are impermeable and these and the wall finishes are readily cleanable. The home has an infection control policy and the inspector observed this. Instructions are in place for the washing of soiled linen. DS0000057633.V331569.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area is good. Service users benefit from a staff team who are appropriately trained to ensure that service users are cared for by skilled staff at all times. There are effective recruitment procedures in place to ensure service users are protected from harm. There is a staff training and development programme which ensures staff fulfil the aims of the home and meet the changing needs of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff appear to have a good understanding of service users’ needs and were gentle and interactive with service users. Staff are aware of the organisation’s policies and procedures and understand how their work, and that of other staff, promotes the main aims of the home. This is achieved through staff meetings, and supervision sessions. There is evidence in service users plans of care that individual needs are met, with particular attention to gender, age, culture and personal interests. DS0000057633.V331569.R01.S.doc Version 5.2 Page 23 There were no staff members under the age of eighteen and there are no staff under the age of twenty one left in charge of the home at any time. At the time of the inspection the home have achieved 80 of staff who have completed NVQ training. A random selection of staff files were examined including those of the most recently appointed staff. These were looked at and found to contain evidence of satisfactory recruitment checks being undertaken, including Criminal Records Bureau checks and proof of identification. There is an induction programme in place to ensure that new staff members are familiarised with the organisation and their roles and responsibilities and provides the staff member with a personal development portfolio. This includes fire safety, moving and handling techniques and core skills training. Training records reflect that staff have received mandatory training and this appears to be up to date for all staff. There is specialist training available for staff, an example of this is dementia training, non-violent crisis intervention and the role of the care worker. Staff confirmed that there are regular staff meetings. DS0000057633.V331569.R01.S.doc Version 5.2 Page 24 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. Quality in this outcome area is good. The registered manager is supported well by the staff team in providing clear leadership and demonstrating an awareness of their roles and responsibilities to the benefit of service users. The home operates a consistent approach to quality assurance resulting in the home being proactive in identifying issues that may effect the well being of services users. There are systems within the home that are used to ensure that service users health, safety and welfare are protected and promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of this inspection the previous registered manager had recently left and the team leader was temporarily managing the home with support from the organisations care and training coordinator. The inspector was informed DS0000057633.V331569.R01.S.doc Version 5.2 Page 25 that the post of manager at Parry House is shortly to be advertised. Staff spoken to understand and can relate to the aims and purposes of the home. This is usually achieved through regular staff meetings, staff supervision and annual appraisals. There is a communications book, handover meetings, service user plans and training. The home has a complaints procedure in place and a whistle blowing policy, which enable staff and service users to voice concerns and affect the way in which the service is delivered. The home has undertaken a service satisfaction questionnaire that was sent to relatives and representatives of service users and the inspector observed evidence of this. Regulation 26 reports are available for inspection. Records were seen for fire safety. There are service certificates for fire equipment and emergency lighting. There are records of weekly fire alarm testing and staff training is up to date for all care staff working in the home. Fire drills are carried out with the full involvement of the service users and these are recorded in the homes fire safety records. A generic fire risk assessment for the home is in place dated 16/08/06. Service reports are in place for the PAT testing dated 16/08/06 and gas appliances dated 11/06/06. There is evidence of water temperature recording, work placement risk assessments, accident and incident reports and health and safety risk assessments. Following the previous inspection a requirement was issued for guidelines to be in place regarding COSHH spillages. It is pleasing to see that this has been complied with. The inspector looked at Infection Control guidelines that are available for all staff. DS0000057633.V331569.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 28 3 29 3 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 3 X 3 X X 3 X DS0000057633.V331569.R01.S.doc Version 5.2 Page 27 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. 1 Refer to Standard YA6 Good Practice Recommendations It is strongly recommended that the care plans contain a detailed action plan that sets out in detail the action to be taken by care staff to ensure the assessed needs of service users can be fully met. DS0000057633.V331569.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 DS0000057633.V331569.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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