Care Home: Pendeen Residential Home

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What the care home does well The house is comfortable and warm. There is plenty of good food. People have enough things to do to be happy. There are always enough staff to help and people get all the help they need. Each person can have their room just as they want it. The staff know how to help people and the staff do their best. The staff are safe to be with.If you want to live there the staff will make sure you can find out all about what it is like. What has improved since the last inspection? The staff are learning more ways to help people. What the care home could do better: It should always be written down whenever a person isn`t allowed to do something because they wouldn`t be safe. Some of the assessments of risks in the building should be done better. The windows on to the communal stairwells should be covered so that people from outside cant see in. The results of the quality assurance process should be given to the service and the people that live at Pendeen. CARE HOME ADULTS 18-65 Pendeen Residential Home 63 Pendeen Crescent Southway Plymouth Devon PL6 6RF Lead Inspector Brendan Hannon Unannounced Inspection 6th December 2007 9:30 Pendeen Residential Home DS0000003526.V345275.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 Pendeen Residential Home DS0000003526.V345275.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. Pendeen Residential Home DS0000003526.V345275.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pendeen Residential Home Address 63 Pendeen Crescent Southway Plymouth Devon PL6 6RF 01752 794447 01752 794447 headoffice@durnford.org 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) The Durnford Society Ltd Mrs Kathryn Fiona Kerry Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (9), Physical disability (9), of places Physical disability over 65 years of age (9) Pendeen Residential Home DS0000003526.V345275.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2006 Brief Description of the Service: Pendeen is a care home for nine people who have a learning disability. The service offered is for both men and women with a learning disability over the age of 18 and under the age of 65. The home is managed by the Durnford Society Ltd, a Plymouth based voluntary organisation. Pendeen is situated on the ground floor level of a Plymouth City Council housing project. The second floor of the building contains council flats. The home is in a residential suburb of Plymouth. The home has nine single bedrooms, a large lounge, a dining area and a conservatory. A garden patio area is accessed from the conservatory. The home is within walking distance of some local shops and is on a bus route. People that live at this care home have access to two mini buses that are fitted with tail lifts. The home is fully wheelchair accessible and has hoists and appropriate facilities available. Many of the people that live at the home have both significant physical disabilities and a learning disability. The people that presently use the service have a mixed range of ages and abilities. The fees charged by the home range from £531 to £1287 per week. Pendeen Residential Home DS0000003526.V345275.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. Preparation for the inspection included analysis of the CSCI Annual Quality Assurance Assessment, the last inspection report, and contacts with the home over the last 12 months. An inspection plan was developed from this information. The inspector was in the home from 9.30am to 4.30pm on 06/12/07, and met with the Registered Manager, deputy manager and the staff on duty. The following methods were used to carry out the inspection. The care of three people that use the service was tracked during the inspection. People that use the service were met. Staff personnel and training information was sampled during the visit to the home. We toured the building during the inspection. An opinion on the service was sought from Plymouth Social Services, and from the Plymouth Community Learning Disability Health team and their responses were positive. The care staff were surveyed and two responded positively. Various areas of documentation were inspected to evidence compliance with the National Minimum Standards. Documents inspected included assessments of peoples’ needs and their care plans and risk assessments, various records including medication administration records, staff records, and health and safety records. All the information gathered during the inspection was considered in the writing of this report. What the service does well: The house is comfortable and warm. There is plenty of good food. People have enough things to do to be happy. There are always enough staff to help and people get all the help they need. Each person can have their room just as they want it. The staff know how to help people and the staff do their best. The staff are safe to be with. Pendeen Residential Home DS0000003526.V345275.R01.S.doc Version 5.2 Page 6 If you want to live there the staff will make sure you can find out all about what it is like. 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. Pendeen Residential Home DS0000003526.V345275.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 Pendeen Residential Home DS0000003526.V345275.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): 1,2,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s pre-admission processes ensure that people that are considering using the service are provided with information about the home as well as having the opportunity to experience life in the home before admission. This enables them to make a properly informed decision. EVIDENCE: There have been no recent admissions to the home. The Durnford Society has an appropriate admission policy and procedure. The pre-admission process thoroughly explores a persons support needs before they are offered a place at the home and each person is enabled to visit the home on different occasions to meet with the other people that live there and the staff. The organisation provides a written language Service User Guide. The Guide is not yet available in other formats such as in audio or in pictorial form. Each person that is considering using the service is supported to make an informed choice based on the information in the Guide, from visits to the home, and from explanations from the staff. Pendeen Residential Home DS0000003526.V345275.R01.S.doc Version 5.2 Page 9 The Registered Manager stated that everyone that uses the service has received a Service User Guide and a statement of terms and conditions of residency. Pendeen Residential Home DS0000003526.V345275.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a clear and comprehensive care planning process, which provides staff with the information they need to satisfactorily meet the needs of people that use the service. People that use the service are enabled to manage as much choice as possible in their day to day to lives. EVIDENCE: Every person’s personal file contained an adequate care plan of how the service will meet their needs. All of the care plans and assessments of need are being redeveloped. The new care planning includes people’s short and longer term goals. Half of the care plans have been completed and are much more useful and informative documents. The management of the home was advised to complete this process of redevelopment. Each persons care plan and individual risk assessments are reviewed every 8 weeks and this was recorded. Pendeen Residential Home DS0000003526.V345275.R01.S.doc Version 5.2 Page 11 Three peoples files were examined. All had good detailed records regarding medication, personal care needs and methods of communication. Various specific charts were being used effectively to monitor people’s health needs. This amount of detailed information enabled care staff to meet the assessed needs of each person that lives at the home. Comprehensive and detailed care planning assists staff to provide consistent support to the people that use the service. Due to the complex needs of the people that use the service many have limited ability to make decisions independently. The care staff encourage people to make many decisions and choices on everyday issues, such as taking part in activities, and expressing meal preferences. Some people are able to assist with the day-to-day running of the home, however only a few of the people are able to assist with managing their own finances and none can manage their personal finances independently. Individual risk assessments have been completed for each person and these were available on file. These risk assessments are based on risk and choice. Many risk assessments relate to everyday issues including personal care. The managers said that any restrictions on choice or freedom had been agreed with the person affected and other people involved in the person’s care. Any restrictions in place were made to protect the person’s health and safety. Not all the restrictions in place had been documented. Assessment of peoples individual risks were generally good but those missing included issues such as medication administration, use of an audio monitor, key use, and hard flooring in bedrooms. Though the managers could clearly state how these issues are managed it was recommended that these assessments should be documented. There were records showing the involvement of advocates to speak on behalf of the person. As many of the people that live at the home have communication difficulties and find it difficult to make decisions independently it was felt most would benefit by having an advocate. The Registered Manger is seeking further advocate support for some of the people that use the service. Pendeen Residential Home DS0000003526.V345275.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): 11,12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people that use the service can learn life skills, attend clubs, participate in community and leisure activities, choose their own daily routines and enjoy food of their choice. EVIDENCE: The service encourages people to participate in social activities and develop their social skills. This is assisted by providing transport and staff to support access to community facilities, day centres and to provide outings. Peoples files contained information about their activities. Local community facilities such as, local shops and banks are used. People take regular walks to use these facilities. Pendeen Residential Home DS0000003526.V345275.R01.S.doc Version 5.2 Page 13 Three people regularly visit social clubs in Plymouth each week. The home does provide transport and people that use the vehicles reimburse the organisation on a monthly basis depending on how much they have used the vehicles. Some of the activities enjoyed by people that live at Pendeen, outside the home include, Arts and crafts, music groups, the library, theatre trips, concerts, restaurants, and local attractions such as the National Marine Aquarium and the regional zoos. Within the home activities such as, aromatherapy, use of sensory equipment, table top games, music, television, arts and crafts, and hair and make up sessions are some of the things people enjoy doing. Some people had information about the holidays they had attended this year, recorded on their files. This information recorded trips to, Wales, Jersey, Butlins and the Isle of Wight. The home has a weekly activity plan. These planned activities are confirmed by entries in peoples’ daily diaries. All bedroom doors only have locks that can be locked from the inside for privacy. The staff are able to override the lock from the outside. These locks do not offer a key which a person could use to secure their personal belongings while they are out of their room. None of the people that currently us the service have been offered a key to their bedrooms. The information about why they are not able to hold a key has not been recorded in care plans. The homes menus were examined and staff confirmed there is a good budget to purchase food. The staff spoken with agreed that the home provides good quality and wholesome food. The menu is re written monthly and is based on peoples’ likes and dislikes. Specialist dietary needs are met. The main weekly food shopping is carried out at ordinary supermarkets. There is a full record of every meal taken by each person and food and fluid intake charts are in use. Fridge and freezer temperatures were seen. People that live at Pendeen receive a choice of good quality food and their nutritional needs are met. Pendeen Residential Home DS0000003526.V345275.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People that use the service receive excellent healthcare support and their privacy and dignity is protected. Health care needs are addressed as soon as they are identified. EVIDENCE: Staff were observed providing people with personal support. This was carried out in private and the dignity of the people receiving personal care was maintained at all times. Personal care procedures are detailed in each persons care plan. Moving and handling information is supplied to staff through separate risk assessments. Physiotherapist and Occupational therapist assessments are recorded on people’s individual files. Some people have been supported to purchase wheelchairs with custom shaped seats to assist their comfort. People that live at the home receive regular dentistry, optician support, and chiropody as necessary. The home has a key worker system in operation. Through their in depth knowledge of the person they support, e.g. their likes and dislikes, keyworkers help people to make daily living choices and decisions. The keyworker is Pendeen Residential Home DS0000003526.V345275.R01.S.doc Version 5.2 Page 15 responsible for a number of specific tasks including review and amendment of the care plan, ensuring health checks take place, and supporting the person to arrange an annual holiday. Each person’s health is monitored for any change in their condition, and any extra provision or support that is needed is arranged. This was well documented in people’s records. In particular information and chart records were well organised and maintained. The management at the home said that the number of epileptic seizures had gone down due to the close monitoring and support. All of the people that use the service have a Health Action Plan. The format was supplied by community learning disability services and has been completed by the staff at the home. These action plans help to clearly inform services about each persons health needs. The staff seek advice from outside professional agencies when required. There were frequent mentions of this support in care planning and peoples records. All the people that use the service have GPs with a good knowledge of the care home. People that use the service also receive support from the Speech and Language service and Psychiatry. A monitored dosage system is used to administer medication that is in the safekeeping of the care home. This medication was locked away safely and tidily in the homes medication room. There is a list (profile) of each person’s medication on file. Medication Administration Records were well maintained. All staff receive medication administration training from the homes pharmacist. The procedure used by staff to administer and record medication is effective and was seen being properly carried out. There is a procedure for the emergency administration of epilepsy medication. Only staff that have received specialist training may give this medication. All medication was thoroughly recorded and audited weekly. The Controlled Drug record was well maintained and the stock was well managed. The service is commended for the quality of the medication administration carried out by the home. Pendeen Residential Home DS0000003526.V345275.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People that use the service are protected from abuse, neglect and self-harm. People that live at the home can be confident that the Registered Provider always deals with complaints or concerns seriously and takes action quickly. EVIDENCE: The homes complaints procedure is in a more accessible form using symbols as well as written language. This procedure is up to date and was on display in the front hallway of the care home. A copy of it is also in the Service Users Guide and in the homes Statement of Purpose. The Commission has not received any complaints, since the last inspection. The home was advised to give a copy of the complaints procedure to the relatives of people that use the service. All the staff have received adult protection training through the in house induction and LDAF levels 1 2 training. This ensures they are aware of their responsibilities should they suspect a person is at risk of abuse. A copy of The Plymouth City Council Alerters guidance was present in the home. The Durnford Society has a policy of renewing staff Criminal Records Bureau checks on a regular basis to ensure the ongoing safety of the people that use the service. Pendeen Residential Home DS0000003526.V345275.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment is generally good, providing the people that live at Pendeen with a comfortable and homely place to live. EVIDENCE: The premises are accessible to people with all levels of mobility. The whole service is on one ground floor level of a council housing development. It is comfortable, well furnished and clean. All bedrooms are single rooms and each person’s bedroom is decorated as the person wishes or to reflect their personality. Every bedroom contained many personal possessions and also often sensory equipment, such as bubble tubes and light projectors. All the furnishings were of good quality. The home has a large conservatory which is entered from the dining room. A large raised patio area extends on the same level from the conservatory into the rear garden to make it accessible to the people that live at the home. The main kitchen has been refurbished and fitted with a new kitchen. Pendeen Residential Home DS0000003526.V345275.R01.S.doc Version 5.2 Page 18 There are large windows on to the communal stairwells. These stairwells allow people that live on the upper floor of the housing scheme to enter and exit the building. Some of these windows should be better obscured to support the privacy and dignity of the people that live in the home. The homes laundry facilities are sufficient to meet the needs of the people that use the home. The home benefits from having a sluice facility. Infection control practices are good and items of personal protective equipment, such as disposable gloves and aprons, are easily available to staff. Paper towels are available in all bathrooms and toilets for people to use to dry their hands. Guidelines are available on infection control practices and the procedures in use are effective. It was agreed that the floor covering in the medication administration room would be replaced due to wear. Over the past 12 months new dining room furniture and two bedroom carpets have been purchased. A new shower room has been built. Two bedrooms have been redecorated. A new communal flat screen television and digital set top boxes have been installed. Pendeen Residential Home DS0000003526.V345275.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff have a good understanding of the support needs of the people that live at the home. There are enough well trained and experienced staff provided by the service to meet the needs of the people that live at the home. EVIDENCE: The home has a consistent staff team who have a good understanding of the needs of the people that live there. Throughout the inspection staff were observed responding sensitively and respectfully to requests from people that use the service. Staff seen on duty were friendly and good-natured. They interacted well with the people that live at the home. Discussion and personnel records confirmed that the manager and staff are aware of when to ask for advice and guidance from other agencies, including the specialist learning disability services. Care plans and risk assessments highlighted that people that use the home have high support needs. The Registered Manager said that the following minimum staffing level is always provided and is sometimes exceeded. From Pendeen Residential Home DS0000003526.V345275.R01.S.doc Version 5.2 Page 20 8am till 8pm there are at least 5 staff, from 8pm till 8am there are two waking staff. The staff rota confirmed these arrangements. The Registered Manager said that the staffing level was adequate to meet the needs of the people that use the service. A thorough training programme is run by the organisation to ensure that the needs of the people that use the service are fully met by skilled staff. The organisation is training new staff in the Learning Disability Award Framework (LDAF) as part of their induction. This qualification gives staff specific skills to work with people with a learning disability. This induction training then forms part of an NVQ2 and enables staff to meet peoples’ needs soon after beginning work at the home. At present 33 of the staff team have an NVQ2, or above, qualification in care delivery. The Registered Manager hopes this will rise in the future when a further 4 staff of the 15 person staff team complete their NVQ2 courses. A sample of staff records were seen, which confirmed that the homes recruitment procedure is robust and ensures the protection of people that live there. All staff had a Criminal Records Bureau (CRB) check and a Protection of Vulnerable Adult (POVA) register check. Key-worker and staff meetings take place on a regular basis. Staff are receiving regular formal 1:1 supervision, though the planned frequency of one meeting every two months is not yet being achieved. Pendeen Residential Home DS0000003526.V345275.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The day-to-day running of the home is being well managed to meet the needs of the people that use the service. EVIDENCE: The Registered Manager, Kathryn Kerry, has been in post for two years. She is a qualified Social Worker and is currently undertaking the Registered Managers Award. She explained how further training she received has helped to maintain her social work qualification, as did being a facilitator in support of Person Centred Planning (PCP). All records inspected were well maintained. The Registered Manager said she was continuing to improve the care-planning and recording systems to ensure that information is easily accessible and understood by those providing care. Pendeen Residential Home DS0000003526.V345275.R01.S.doc Version 5.2 Page 22 The records of people that use the service were organised in a way that made it easy for the inspector to get a picture of people’s needs, and to understand how their needs were being met by the home and other agencies. These records assist management in monitoring the delivery of support to people that live at the home. Records showed that appropriate fire safety procedures have been carried out. All staff have been appropriately trained in fire protection. There is an appropriate hold open device on every door except for the bathroom and toilet doors. The latest Environmental Health Department inspection report was good and contained no recommendations. The electrical wiring certificates both for the buildings wiring and for domestic items was seen. The gas appliance certification was seen. Accident records were accurate and were being appropriately maintained. Appropriate risk assessments are in place to ensure the safety of every unrestricted hot water outlet. Thermostatic control valves have been fitted to all hot water outlets in the bathrooms and the shower room. Some window openings above ground floor level are not restricted and some radiators are not covered. Although there is a general risk assessment each window opening and each radiator has not been individually risk assessed. Good health and safety practices help to keep the people that live at the home safe. The organisation has redeveloped the Quality Assurance system. A quality assurance process will be carried out every year. There is a separate quality assurance process for staff. A quality assurance process was carried out for people that use the service, their relatives, and professionals earlier in the year. Student nurses from the local community learning disability team have in person gathered the views of the people that use the service. The service has made significant efforts to gather information objectively and so produce meaningful feedback on the service from those who use, or are in contact with it. The outcomes from this process have still not been reported even though the information was gathered some time ago. The organisation should collate the outcomes for the process and feed them back to the service, the people that use it, and their relatives. Pendeen Residential Home DS0000003526.V345275.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 3 2 3 3 X 4 X 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 2 25 3 26 3 27 3 28 3 29 3 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 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 X 3 X 2 X 3 2 X Pendeen Residential Home DS0000003526.V345275.R01.S.doc Version 5.2 Page 24 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. 2. Refer to Standard YA6 YA16 Good Practice Recommendations Care planning should comprehensively document all risk assessment issues and restrictions of choice. Appropriate key operated locks should be fitted to enable the offer of a bedroom door key to be available to people that use the service and to support people to learn to manage a key. The windows on to the communal stairwells should be fully obscured. The outcomes of the quality assurance process should be collated and passed to the service, the people that use it, and their relatives. 3. 4. YA24 YA39 Pendeen Residential Home DS0000003526.V345275.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Pendeen Residential Home DS0000003526.V345275.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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