Care Home: Sandringham Villa

What the care home does well Staff we spoken with and from surveys indicated that morale in the home was good. Staff were cheerful and interacting with residents in a positive and caring manner and people were treated with respect and dignity The home was found to be clean, warm and in good order. Residents were calm relaxed and looked well cared for. All of the residents surveyed said "Staff always treat me well" comments included, "I think the care is brilliant", and "I am grateful for all the support I receive from Sandringham Villa". What has improved since the last inspection? In the statement of purpose contact details for the commission have been updated. Appropriate policies and documentation to record drug receipts and disposals and review the self-medicating policy are in place in accord with the Pharmacists advice.All staff receive alerter level safeguarding adults training and are inducted into the home and local authorities policies in this regard. What the care home could do better: If a disclosure is receive folowing CRB checks make a written risk assessment in support of decision to employ. Carry out individual social and leisure assessments and Develop care pathways to met individuals identified aspirations and need. A copy of the gas safety certificate should be submitted following completion of the safety inspection. CARE HOME ADULTS 18-65 Sandringham Villa Sandringham Villas 97-99 Locking Road Weston-Super-Mare Somerset BS23 3EW Lead Inspector Andrew Pollard Unannounced Inspection 13th November 2008 10:00 Sandringham Villa DS0000070030.V373101.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 Sandringham Villa DS0000070030.V373101.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. Sandringham Villa DS0000070030.V373101.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandringham Villa Address Sandringham Villas 97-99 Locking Road Weston-Super-Mare Somerset BS23 3EW 01934 613998 01934 613999 knightwood.care1@yahoo.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Knightwood Care Limited Mr D Hoskins Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places Sandringham Villa DS0000070030.V373101.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with Nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following category: Mental Disorder, excluding learning disability or dementia (Code MD) The maximum number of service users who can be accommodated is 9. 2. Date of last inspection 27th November 2007 Brief Description of the Service: This is a nine bedded home for adults with mental ill health who require mental health nursing care. The home is near the town centre and the seafront. The home offers beds for rehabilitation or respite and short-term care. The staff offer a structured and therapeutic programme and environment, which treats people with respect and empowers them toward leading a more independent life. Sandringham Villa DS0000070030.V373101.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 two stars. This means that the people who use the service experience good quality outcomes. The following methods of evidence gathering has been used In the production of this report; observation, AQAA questionnaire, discussion with residents and staff, residents surveys, tour of the home and sampling policies, records, care plans. The emphasis of the service is predominantly rehabilitation and some continuing care. The aim is to lead people toward a more independent lifestyle in the community. In addition staff strive to enhance the quality of life for the residents. The staff team are experienced with the needs of the resident group. The skill mix and level of Registered Nurse input is appropriate for the resident group. What the service does well: What has improved since the last inspection? In the statement of purpose contact details for the commission have been updated. Appropriate policies and documentation to record drug receipts and disposals and review the self-medicating policy are in place in accord with the Pharmacists advice. Sandringham Villa DS0000070030.V373101.R01.S.doc Version 5.2 Page 6 All staff receive alerter level safeguarding adults training and are inducted into the home and local authorities policies in this regard. 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. Sandringham Villa DS0000070030.V373101.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 Sandringham Villa DS0000070030.V373101.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): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective clients and their families are given relevant information and terms and conditions in written or verbal form about the home to assist them in deciding if the home is suitable for their purpose. As a result of effective assessment of needs prospective residents can be confident that these will be met in a manner that suits the individual. EVIDENCE: The home has an equalities and diversity policy and is open to admissions from people of all backgrounds and cultures. Sandringham Villa is a person centred home is relaxed and homely and seeks to maintain residents life skills providing therapeutic support where needed. The statement of purpose and service user guide have been written in accord with the regulations and schedules and provide clear information for residents, minor revisions will be made as the service develops and the residents should be encouraged to take part in the process. The contact details for the commission have been updated with the new Sandringham Villa DS0000070030.V373101.R01.S.doc Version 5.2 Page 9 address. The details of the new manager need to be included in due course. There are six residents in the home one in hospital and one person awaiting admission. There have been five successful discharges with residents moving to independent living. All admissions are managed through the community mental health team and social services who carry out full assessments of peoples needs. The prospective residents, professionals and relatives are consulted where appropriate. The manager or other Registered Nurse (RN) meet and assesses all people prior to admission. Prospective residents are offered half-day visits and meals as a method of determining if the home suits them. Admissions are tailor made for individual residents circumstances. The views of the existing residents are taken in to account regarding any admission. A report of the home admission assessment is sent to the referring/funding organisation confirming the homes ability to meet the assessed needs. Surveys completed by residents recently admitted indicated that the admission process had been well managed and successful and they were happy with the placement. A full multidisciplinary review of the placements is carried out in the weeks soon after admission. Residents have an admission agreement setting out their terms and conditions and rules of the house agreed. All residents can read and have signed contracts. Sandringham Villa DS0000070030.V373101.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. Care plans detail residents care needs they are clearly written and give directions to staff. A person-centeredness approach enhances the quality of care for residents. Residents are involved with decision-making and consulted about the running of the home within the limits of their willingness or ability to take part. Sandringham Villa DS0000070030.V373101.R01.S.doc Version 5.2 Page 11 EVIDENCE: All residents have a person centred care plan, which they were encouraged to take an active part in developing along with the key worker (Registered nurse). Some residents will require staff support of an advocate or family member in this process due to their mental health needs. The new manager intends to further develop care planning by the introduction of care pathways in the coming months. All of the residents who responded in the survey said, “Staff listen and act on what they say”. Each element of the care plan is written up separately and signed by the resident. Evaluations and daily records are written in the case file. Enhanced level care plans and medical information are also part of the case file. There are regular multidisciplinary reviews to which residents and or their representative are invited. All residents have a named Registered Nurse (RN) key worker and Care Assistant associate worker. Any entries in the daily records made by care staff are read and counter signed by an RN. Individualised risk assessments and behaviour agreements have been written and are held in each person’s case file along with skills assessments and competences. Any restrictions on personal freedoms were documented in care plans. Residents meetings are both formal and informal and the staff are empowering toward the residents and encourage their involvement in decision-making. People indicated in the survey “they make decisions about what they do each day” and at weekends. Sandringham Villa DS0000070030.V373101.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): 11,13,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff strive to enhance the quality of life for the residents. Residents regularly make use of community facilities and services. From speaking to residents and reviewing records it was evident that the food provided is to peoples liking and offers a generally balanced diet. EVIDENCE: The emphasis of the service is rehabilitation and some continuing care, to maintain and enhance the existing life skills that people have. Where appropriate the long-term aim is to lead people toward a more independent lifestyle in the community. Most of the residents make use of community services and facilities. However, The mental health needs of the residents may require staff support for this. Sandringham Villa DS0000070030.V373101.R01.S.doc Version 5.2 Page 13 An activity organiser is no longer employed. In the main these activities are arranged on a one to one basis facilitated by the team leaders and based around the resident’s choice, however some small group activities are undertaken. Some residents make use of a local drop-in and activity centre. The home has taken on an allotment and started to keep chickens both of which are managed by residents with staff support. Various events such as BBQ’s and firework an evening has taken place and a Christmas meal is being planned. Former residents who are living locally are invited to these events. It is hoped to plan some summer holidays for individuals and small groups next year. At present there are no detailed social assessments and care plans for individuals, however it is intended to introduce such as part of the care pathway approach. People who responded to the survey said, “You can choose to do what you want in the, evenings and at weekends.” Residents are engaged in house keeping task such as room cleaning, laundry and cooking as agreed in their weekly programmes. Residents will be encouraged to take up voluntary work or employment as their health allows. All residents have contact with family members or friends. Family and friends are welcome to visit the home at the invitation of the resident. There are three meals a day and the times are flexible. There is active involvement of the residents in choice of meals and requests for individual likes are discussed at the weekly meetings. Menus are planned on a week-by-week basis and residents said they liked the food. Food records showed evidence of a balanced diet. Residents and staff eat main meals together. Residents are able to prepare breakfasts, snacks and drinks with varying levels of support. The home employs a chef who actively teaches residents cooking skills. There are no special cultural needs at present. There is one person who is a diet controlled diabetic. Sandringham Villa DS0000070030.V373101.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. Appropriate personal and nursing care is offered to residents to maintain or their health, well-being and developing people’s independence. Residents are treated with respect and given choice in how needs are met. Proper arrangements are in place for residents to access healthcare services and for the administration of their medication to maintain or improve their quality of life. Sandringham Villa DS0000070030.V373101.R01.S.doc Version 5.2 Page 15 EVIDENCE: Registered nurses administer all medication. The Commission pharmacist carried out an announced random inspection in December 07 and gave advice and guidance about the management of medication in the home. A full report on this visit is available upon request. The medication policy has been updated including risk assessments to reflect current practice, including a policy for the use of homely remedies. Medicines administration record sheets show full dosage instructions and any additional advice provided on the medicine label. The records were up to date and in order. A policy is in place to safeguard residents who are self-medicating. One resident is undertaking supervised self-medication. It is intended that in time all residents’ will self medicate as part of preparation for discharge. Lockable storage is available in room for residents to keep their medicines. All residents remain under the care of a consultant who visits at least every four to six weeks. Regular multi disciplinary care reviews take place and are fully documented. Each person has a Care Co-ordinator, RN key worker and HCA associate worker who work with the residents in the overall management of their care. The majority of residents are no longer on section and have informal status. All residents are registered with their own GP who works in conjunction with the consultant and makes referrals for any paramedical services required. Dental checks and eye tests are arranged for those who wish for such. People are able to be independent in accessing medical services but sometimes require general support. Sandringham Villa DS0000070030.V373101.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. The staff are aware of the complaints and “in house” safeguarding adults policies and receive training to protect residents from abuse. The residents are aware of the complaints procedure and attend meetings to give their views on the running of the home. EVIDENCE: The complaint procedure is included in the Service User Guide and on public display. All residents who responded to the survey indicated, “They were aware of whom to complain to if they were unhappy with their care”. Each resident has seen a copy of the complaint procedure. The residents surveyed and spoken to had no complaints. The N Somerset “No Secrets” guidance was available. There is a whistle blowing and an internal Adult Protection policy. All of the staff have attended or are being booked to attend Local Authority alerter level Safeguarding training, which will be completed by the 17 December. Ms Phillips recently uncovered an alleged theft of resident’s money by a member of staff, now suspended. The police Social Services and CSCI were Sandringham Villa DS0000070030.V373101.R01.S.doc Version 5.2 Page 17 informed and investigations are continuing. This matter has been wellmanaged and decisive action taken. The Ms Phillips the RI has attended investigators training with the Local Authority. Copies of the General Social Care Council code of practice are available individually to the care staff. A number of residents manage their own finances within any limits agreed in care plans. Other monies are held in safe keeping on behalf of residents. Clear and up to date ledger records are maintained for all monies. Two residents have their financial affairs managed by the Court of Protection. Sandringham Villa DS0000070030.V373101.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): 24,27,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a safe and well maintained clean environment with good furnishing and décor, their needs are met by having bedrooms and communal rooms and facilities which are suitable for their purpose and meet the resident’s wishes. EVIDENCE: The home is suitable to meet the current needs of the residents who are all ambulant. There is the potential for ground floor rooms to be made available should someone be admitted with limited mobility. A new disabled bathroom has been Sandringham Villa DS0000070030.V373101.R01.S.doc Version 5.2 Page 19 installed, which is assessable to people with physical disability. There are bathrooms and showers that are suitable for the residents needs. A therapy room is provided and various alternative therapies such as massage and aromatherapy which are provided free of charge. Communal areas include a dining room, lounge and activities area. A new floor is being laid in the activity room. The home was clean and in good general order. Residents take some responsibility for maintaining their own rooms. The fittings and furnishings are of a domestic nature and are in good order. The heating, lighting and ventilation are satisfactory. Many rooms have recently been redecorated and all will be completed in a rolling programme following rewiring of the building. Appropriate arrangements are in place for maintenance and servicing of plant and equipment, for which records are kept. Rooms are lockable and residents have access to keys if they wish. The house is a no smoking area, however garden house is provided for those who wish to smoke. The kitchen is of an appropriate type and size. The Environmental Health Officer inspected kitchens, the risk assessments and record keeping. The home has been awarded 4 stars. The laundry is well equipped including a new sluicing machine. Residents have their own linen and manage their own laundry. There are plans to relocate the laundry as part of plans to create a further three single rooms, appropriate applications have been submitted for this purpose. Department of Health guidelines on infection control are available. Proper arrangements are in place to dispose of clinical waste. Sandringham Villa DS0000070030.V373101.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): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An appropriate and robust recruitment procedure is in place. The staff are experienced and trained to meet the individual and joint needs of the residents. The staff skill mix and staffing levels are conducive to maintaining and enhancing the resident’s quality of life. The manager demonstrated a commitment to training. EVIDENCE: Staffing levels are in accordance with the number and needs of the residents. Resident dependency is quite variable depending upon people’s mental state. The skill mix and level of Registered Nurse input are appropriate for the resident group. All Registered Nurses are Registered Mental Nurses. The manager will work supernumerary 5 days per week and be a second nurse on duty those days. Ms Phillips the RI who is a registered nurse is also on the premises frequently. Sandringham Villa DS0000070030.V373101.R01.S.doc Version 5.2 Page 21 There is a part time administrator supporting the manager. The staff team are experienced with the needs of the resident group and are client centred. The residents who responded to the survey said, “That the staff treat them well”. One staff survey was received which was positive in all regards. The staff spoken with enjoyed working in the home and considered that a good service was provided for residents. There are adequate staffing arrangements for housekeeping and catering services as residents are expected to take a certain amount of responsibility for household chores as part of their rehabilitation programme. There is a robust recruitment policy in place. An equality and diversity policy underpins the employment practices. The home has created an appropriate CRB log and the original disclosures confidentially disposed of after counter signature by a CSCI inspector. Two disclosures required risk assessment, which had been carried out, but no written record was made in support of the decision. CRB checks are carried out annually for RN’s. NMC checks and health checks are carried out and professional references sought. The manager and or RI conduct interviews and written records are kept. All the required staff records are held in the home. All staff have written terms and conditions of employment. The manager demonstrated a clear commitment and focus on training to enhance the quality of life and standards of care for residents. All new staff completes a detailed induction and orientation process. There are training records of learning and updating in areas relevant to residents care needs. Staff benefit from a proactive mental health and stress reduction policy and support offered by the home. All Health care assistant staff have National Vocational Qualification (NVQ) level 3 and others are to commence programmes through local collages and providers. A rolling programme of updates in Health & Safety, 1st aid, food hygine and load handling takes place. All staff receive appraisal and supervision by a cascade system of which written notes are made and personal development plans updated. One of the Registered nurses is a senior clinical nurse specialist and offers a range of peer support and clinical updating and perceptorship for newly qualified nurses. Sandringham Villa DS0000070030.V373101.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): 37,38,41,42,43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear management structure in place. The staff are motivated to bring about improvements in residents quality of life. The maintenance of services and facilities and Health and safety arrangements are in place to protect residents and staff. Sandringham Villa DS0000070030.V373101.R01.S.doc Version 5.2 Page 23 EVIDENCE: The newly appointed manager Mr Hoskins has just taken post and is quickly becoming aquainted with the standards and regulations. Mr hoskins has a wide experience in management and of working with the type of resident admitted to the home. The Commission will conduct a full fitness assessment of Mr Hoskins following his submission of a formal application to become the Registered manager. Ms Eaton is the deputy manager and has been in post for some time. Ms Phillips the RI is undertaking a Mental health administratiors qualification and frequently works on site. The manager and nursing staff are experienced in the care for people with mental health needs. There is a committed group of staff and the consistency of staff presence is important to the wellbeing of the residents and maintaining the strategies of care that prevent incidents and tensions arising in the home. Whole team meetings and clinical team meetings will be held regularly to review practice and standards of care. Regular house meetings are held to access the views of the residents on the quality of life and services in the home. All the residents stated that, “The staff treat them well” one person saying, “I am grateful for all the support I receive from Sandringham Villa” and “I think this is really helping me a lot, I think the care is brilliant”. The outcomes from residents surveys were positive and overall they felt the were well cared for and the home well managed. Internal audits on management and performance including surveying residents, staff and relatives for levels of satisfaction with the home are taking place. There is a comprehensive Health and Safety policy. An HCA has been delegated special responsibility for H&S and fire safety issues and is about to undertake fire marshall training. Generic risk assessments are in place and safety audits take place. All residents have individual risk assessments which are regulary reviewed by the named nurse or multidisciplinary team. All staff have received appropriate breakaway and control and restraint training. Personal alarms are available for staff on duty if felt necessary. The electrical installation safety inspection has taken place and a certificate issued. The fire log book, records and alarm/detector maintenance arrangementsare maintained. Staff have attended fire safety training. The manager stated that the gas safety certificate has been issued but was unable to locate it so will fax it through when found. Sandringham Villa DS0000070030.V373101.R01.S.doc Version 5.2 Page 24 Risk assessments will be carried out individualy on residents with regard to risk from hot water. A log of hot water temperatures is being maintained. The home has a comprehensive range of policies and procedures which are kept under review and updated as required. Up to date public and employee liability insurance certificates were on display. The company has up to date Data Protection registration. Sandringham Villa DS0000070030.V373101.R01.S.doc Version 5.2 Page 25 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 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 2 12 X 13 3 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 X X 3 2 3 Sandringham Villa DS0000070030.V373101.R01.S.doc Version 5.2 Page 26 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. 3. Refer to Standard YA11 YA34 YA42 Good Practice Recommendations Carry out individual social and leisure assessments and Develop care pathways to met individuals identified aspirations and need. If a disclosure is receive folowing CRB checks make a written risk assessment in support of decision to employ. A copy of the gas safety certificate should be submitted following completion of the safety inspection. Conduct hot water risk assessments. Sandringham Villa DS0000070030.V373101.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sandringham Villa DS0000070030.V373101.R01.S.doc Version 5.2 Page 28 - 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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