Care Home: Springbank

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What the care home does well Information about this home has been prepared in an appropriate format for the people who live here. The admission protocols ensure that placement is only offered when it is appropriate. The people who live in this home are supported to make their own decisions and are supported by the staff team to live the life they choose. A strong focus upon positive outcomes for those who live in this home, means that the people can be assured of a lifestyle of their choosing. The staff team introduce new opportunities and experiences, to enhance the lives of those that live there. The people who live in this home will receive the help they require with their personal and healthcare needs, and medication systems are safe. There are good procedures are in place to enable people to raise concerns, be listened to and have their concerns acted upon, and also to safeguard them from harm. This is a comfortable and homely home, which is well equipped. Ongoing maintenance and an awareness of peoples changing needs, will ensure that the environment remains appropriate for the people who live here. An established staff team, who are familiar with each person`s needs, means that they will be well looked after. The staff team are well supported by the manager, and are skilled and competent to undertake their role. Springbank is a well run and safe home. It has the best interests of the people who live there and ensures they are at the heart of all decision-making. What has improved since the last inspection? No requirements or recommendations were issued after the last inspection in July 2006. What the care home could do better: It has not been necessary to issue any requirements or recommendation of good practice, following this inspection. CARE HOME ADULTS 18-65 Springbank 1 Charlton Lane Brentry Bristol BS10 6SG Lead Inspector Vanessa Carter Key Unannounced Inspection 30th June 2008 09:30 DS0000026643.V364650.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 DS0000026643.V364650.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. DS0000026643.V364650.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springbank Address 1 Charlton Lane Brentry Bristol BS10 6SG 0117 9505220 0117 9505450 Springbank@Shaw-homes.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) Shaw Healthcare (Specialist Services ) Ltd Mrs Kay Marie Williams Care Home 11 Category(ies) of Learning disability (11) registration, with number of places DS0000026643.V364650.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION 1. May accommodate residents aged 40 Years and Over Date of last inspection 13th July 2006 Springbank is a residential care home registered with the Commission for Social Care Inspection to provide accommodation and personal care for 11 service users aged 40 years and over who have a learning difficulty. The home is an adapted bungalow, and accommodation is arranged over two floors. The first floor of the property contains the staff room, office, and a bathroom and toilet facility. Service users’ individual accommodation, communal lounge, conservatory and dining room are situated on the ground floor. To the outside of the property there is a large private garden, and in close proximity are local shops and amenities. The cost of placement in this home is currently between £1,177 – 1,185 per week. Additional costs may be made for other services and these can be discussed with the home manager. The home is owned and operated by Shaw Healthcare (Specialist Services). DS0000026643.V364650.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. This key inspection was unannounced and took place over one day. A total of six hours were spent in the home. Evidence to form the report has also been gathered from a number of other sources:• Information provided by the Home Manager in the Annual Quality Assurance Assessment (AQAA) • Talking with the deputy manager • Talking with the support workers who were on duty • Observations of staff practices and their interaction with the people who live in the home • A tour of the home • Case Tracking the care of a number of people • Talking with the people who live in the home • Looking at some of the homes records • Information supplied in CSCI survey forms, completed by one person who lives, one relative, and six staff members • Information supplied by one GP What the service does well: Information about this home has been prepared in an appropriate format for the people who live here. The admission protocols ensure that placement is only offered when it is appropriate. The people who live in this home are supported to make their own decisions and are supported by the staff team to live the life they choose. A strong focus upon positive outcomes for those who live in this home, means that the people can be assured of a lifestyle of their choosing. The staff team introduce new opportunities and experiences, to enhance the lives of those that live there. The people who live in this home will receive the help they require with their personal and healthcare needs, and medication systems are safe. There are good procedures are in place to enable people to raise concerns, be listened to and have their concerns acted upon, and also to safeguard them from harm. This is a comfortable and homely home, which is well equipped. Ongoing maintenance and an awareness of peoples changing needs, will ensure that the environment remains appropriate for the people who live here. DS0000026643.V364650.R01.S.doc Version 5.2 Page 6 An established staff team, who are familiar with each person’s needs, means that they will be well looked after. The staff team are well supported by the manager, and are skilled and competent to undertake their role. Springbank is a well run and safe home. It has the best interests of the people who live there and ensures they are at the heart of all decision-making. 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. DS0000026643.V364650.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 DS0000026643.V364650.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, and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about this home has been prepared in an appropriate format for the people who live here. The admission protocols ensure that placement is only offered when it is appropriate. EVIDENCE: Both the statement of purpose and service user guide have been updated and now contain all information as set out in the national minimum standards. An easy read format has been produced, meaning that this information is also available for the people who live in the home. The home has had only one new admission since the last inspection and therefore the process that was followed for this person before admission was examined. Social Services had provided copies of needs assessments and care plans. There was evidence that the home manager had completed a ‘Daily Living Care and Support Assessment’ – this provided a person centred insight into the persons needs. Visits were arranged so that the person could “test drive the home” and meet with the other people who lived there. The home manager then confirmed by letter to the social worker, that the placement was appropriate. The ‘service agreement’ for this person was seen and also the schedule of payment with the local authority. DS0000026643.V364650.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people who live in this home are supported to make their own decisions and are supported by the staff team to live the life they choose. EVIDENCE: The care plans that had been prepared for three people were looked at to determine how each individual person is looked after and how involved they are in deciding what care and support they receive. The plans were person centred, demonstrated that they had been written in conjunction with the person and were based upon an extensive knowledge of the person and what they like and don’t like. Additional information had been added as necessary when needs changed or new needs were identified. The plans detailed what was important for the person and stated what the preferred choices were – “My Daily Routines”. There are clear records of decisions that have been made around the support that is needed for instance “I need help with this because I do not understand…”. Observations made during the inspection were that the people DS0000026643.V364650.R01.S.doc Version 5.2 Page 10 in the home are actively encouraged to make decisions on a day-to-day basis about what they want to do and where they want to go. The people who live in the home are encouraged to participate in the day to day running of the home as much as they are able. One person was observed serving others with cups of tea and also helps with sweeping and cleaning up. Others help out in the garden and keep it neat and tidy. Risk assessments are included as part of the care planning process for each person and result in a management plan being prepared to minimise or eliminate the risks identified. Risk assessments were seen in respects of behavioural challenges, going outside of the home, specific medical conditions, manual handling tasks, and the likelihood of falls. Reviews are made of these management plans on at least a monthly basis. Risk assessment processes do not hinder the development of new skills, but enable the person and staff team to plan how they would achieve something. DS0000026643.V364650.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A strong focus upon positive outcomes for those who live in this home, means that the people can be assured of a lifestyle of their choosing. The staff team introduce new opportunities and experiences, to enhance the lives of those that live there. EVIDENCE: Each person is treated as an individual and their abilities to participate in educational or work related tasks would be assessed on an individual basis. One person currently goes to work and attends workshops on another day. Other people attend various community centres or day centres. A number of people spend the majority of their time in the home, but go out for walks or drives in the local community with staff. Support workers would enable any person to pursue new experiences and to follow any hobbies they may have. One support worker who is delegated to search out new resources, talked about some events locally that they would be exploring - an arts and coffee session, a “Wednesday club” and trampolining. Although it is unlikely that any of the people would be able to participate in this event, it is thought that they DS0000026643.V364650.R01.S.doc Version 5.2 Page 12 may enjoy watching. One person particularly likes to go out for a drive in the homes motor vehicle. In respects of annual holiday’s these are never arranged for all 11 people at the same time. Recently four people have been on holiday to Cornwall and Butlins in Minehead is also a favourite. For some people the benefits of a holiday are outweighed by the challenges it presents for the person – day trips out may be more beneficial. There are currently plans for a day out to Longleat. Other examples of trips that have been organised include pub visits and cinema outings People are encouraged to maintain contact with their families, and staff will assist with making any of the necessary arrangements. Some have visits from family on a regular basis. The home has a vehicle meaning that they have plenty of opportunity to get out and about either for home trips, or singularly with a staff member. Since the last inspection the staff have made picture templates of food dishes and these are posted on the notice board in the dining room to help each person choose what they want to eat. Some people choose to eat their meals in the activity kitchen so that they can watch what is going on out in the road. Discussions with staff evidenced that they know what each person likes to eat and whether they need a softer diet. A list of each person’s likes and dislikes is recorded in their care plans. The main meal tends to be served in the evenings during the week and there is a choice provided if a resident does not like the option chosen by the majority. There are now no concerns about the dietary intake of any person. If anyone happens to be away from the house during a mealtime, their meal will be kept for later. DS0000026643.V364650.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people who live in this home will receive the help they require with their personal and healthcare needs, and medication systems are safe. EVIDENCE: The staff team demonstrated a good knowledge of each person’s specific healthcare and personal needs. Amendments are made to care plans where care needs have changed. It is always recorded where there is preference for a male or female carer to assist with personal care tasks. One person was being assisted to have their hair washed and set and was pleased with the results – “I like having my hair look nice”. Staff were observed to be attentive towards the people they were looking after and taking reasonable precautions to safeguard the person. An example of this was sun cream being applied before taking one person out to the shops. Some people prefer to get up later in the mornings than others and were still in bed at the start of the visit. People who were observed during the course of the inspection were each well dressed and looked clean and well cared for. All the people who live at the home are registered with the same GP – the surgery is next door to the home. They will be assisted to consult with the doctor whenever there is a need, and the same applies to opticians, dentists DS0000026643.V364650.R01.S.doc Version 5.2 Page 14 and podiatry. Where there is a need for other health care professionals, the home staff will enable the person to access the support they need, and this was evidenced in the records looked at for the three people. The homes medication procedures are safe. The pharmacist supplies most of the medications in sealed blister packs. There is a minimal stock of medications kept, and all returns are made in line with good practice guidance. None of the people are able to manage their own medications and this is documented in their care plans. Risk assessments around administration of PRN or “as necessary” medications are kept under review. DS0000026643.V364650.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good procedures are in place to enable people to raise concerns, be listened to and have their concerns acted upon, and also to safeguard them from harm. EVIDENCE: The home’s complaints procedure is displayed on the notice board in the dining room – this is in pictoral format. It is also included in the statement of purpose and service users guide. The people who live in the home who completed CSCI survey forms confirmed that they know how to make a complaint and who to speak to. One person spoken with during the inspection said “I am happy” and everyone appeared to be relaxed and content in the company of the staff team. Observations confirmed that the staff team were approachable, listened to what the people who live in the home were saying to them and responded appropriately with genuine care and kindness. CSCI have received no complaints regarding this service and the GP who completed a CSCI comment card stated that they had no complaints about the home and were “satisfied with the overall care provided to service users within the home”. The home has not received any complaints since the last inspection. The manager was not present during this inspection but has previously demonstrated her awareness of safeguarding adult issues. The staff team also demonstrated their awareness of their role in ensuring that the people who live in the home are protected from abuse, harm or neglect. Protection training is included in the four day induction training for new staff, and on a regular basis thereafter, as Shaw Healthcare deem this training to be mandatory for all staff. DS0000026643.V364650.R01.S.doc Version 5.2 Page 16 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This is a comfortable and homely home, which is well equipped. Ongoing maintenance and an awareness of peoples changing needs, will ensure that the environment remains appropriate for the people who live here. EVIDENCE: Springbank is an extended bungalow, located in the suburban area of Henbury, Bristol. It blends in entirely with its surroundings and does not in any way stand out as a care home. In other words, it is a home in a residential street. There is car parking to the front of the home, and gardens surround the side and rear of the home. A summerhouse has been erected since the last inspection and two of the people who live at the home were keen to show this off. One area of the garden is due to be paved over to make a patio area. This will provide level ground and will be safer for the people who use this space. The gardens were well tended and new plants had just been purchased for hanging baskets and the gardens. The home appeared to be very well maintained. DS0000026643.V364650.R01.S.doc Version 5.2 Page 17 Each person has their own bedroom and all but two were seen during the inspection. The rooms were fully furnished and were decorated to reflect the personality of the person occupying the room. All bedrooms are lockable but currently only one person uses their key. There is an ongoing programme of re-decoration – people are able to choose what colour their room is painted and can choose their bedding and curtains, when their room is due to be done. There are two lounges, one tending to be referred to as the quiet room, a dining room, conservatory and an activities kitchen. There is more than enough shared space for the 11 people who live in the home. New furniture has been purchased for the lounge, but in addition there are specialist chairs for those people who need different furniture to meet their comfort needs. A second shower room has been converted from one of the bathrooms, in recognition of the changing needs of the people who live in the home. This has benefited them as they no longer have to wait for the one shower room to be available. Other items of equipment, such as commodes, hand rails and specialist beds were seen, and staff would arrange for additional equipment as and when needs are highlighted. There are plans for a hoist to be provided, so that it is in place for such time when it may be needed. This evidences that the home is geared up to meet the potential changing needs of people as they age. There is a call bell system installed in each bedroom and all communal areas. The home was found to be clean and tidy on the day of inspection and with no odour. CSCI surveys that were returned said that the home was always fresh and clean. DS0000026643.V364650.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An established staff team, who are familiar with each person’s needs, means that they will be well looked after. The staff team are well supported by the manager, and are skilled and competent to undertake their role. EVIDENCE: Each member of staff is provided with a job description meaning that the staff team are clear about their roles and responsibilities. Signed copies of the document are kept in each workers personnel file. There is a core of wellestablished staff with varying abilities who are skilled and experienced to meet the needs of the people in the home. Observation of staff practice and interactions with the people who live in the home demonstrated that they were approachable, and respectful of those who they were looking after. People were at ease with the staff and there was a great deal of friendly banter, and genuine care shown towards the person. The manager, Kay Williams has already completed the NVQ level 4 in management and the Registered Managers Award, and approximately 48 of the staff team have either already obtained an NVQ level 2 or 3 in care. Two staff are working towards NVQ level 3 and one towards level 2. All new staff DS0000026643.V364650.R01.S.doc Version 5.2 Page 19 will complete a comprehensive induction programme upon starting their employment at the home, and will have a probationary period of employment to start with. These measures will ensure that any new recruit is suitable for the work, are also fully aware of the policies and procedures of the home, and the people receive a satisfactory service, that meets their expectations. The completed programme of one support worker was seen whilst another worker confirmed that they had completed their induction programme. All staff will complete a programme of training that includes fire awareness, safe moving and handling, food hygiene, protection of vulnerable adults (POVA) to name a few. Refresher training is arranged on an annual basis, and a spreadsheet is kept to show when staff need their next refresher. A training file is kept for each worker. The home is currently fully staffed, any spare shifts will be covered within the staff team or by bank staff - the home does not use agency staff. This means that the people who live here will be cared for by staff who are familiar with their needs. Robust recruitment procedures are followed to ensure that the right people are employed at the home – the staff files for four staff members who have been recruited since the last inspection were checked and evidenced this. Full staff meetings are held on a regular basis. From discussions with staff, it is evident that the team are very supportive of each other, have good working relationships, and that the main purpose of their job is to ensure that people’s needs are always met and that they are content. Formal staff supervision has fallen by the wayside recently due to other work commitments but the management team is already making moved to correct this. Examination of records of staff supervision evidenced that for some staff they have received adequate 1:1 supervision. From discussions with staff it is evident that there is a great deal of peer support and an open relationship with the home manager and the deputy. DS0000026643.V364650.R01.S.doc Version 5.2 Page 20 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, 39, 41 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Springbank is a well run and safe home. It has the best interests of the people who live there and ensures they are at the heart of all decision-making. EVIDENCE: Kay Williams has been the home manager since 2005. She has already completed the NVQ level 4 in management and the Registered Managers Award. She is well qualified to run the home. There is also a deputy manager, and they are also hoping to start the NVQ 4 in the near future. A relative who completed a CSCI survey form commented “in my opinion the home is run very well. They look after my relative very well”. Information provided by the home manager (in the AQAA) stated that Springbank had a “comfortable and relaxed ethos” – this was evidenced during the inspection. The people who live there and the staff team all have a say in how the home is run. DS0000026643.V364650.R01.S.doc Version 5.2 Page 21 An area manager from Shaw Healthcare visits the home on a monthly basis and audits arrangements at the home and speaks to both staff and people who live in the home. A report is prepared for the commission. Other checks are completed by the home manager, or other delegated staff during the course of the month. All records were in order. All key documentation needed for the inspection was made readily available evidencing well-organised administrative systems. No health and safety concerns have been noted as a result of this inspection. Staff receive training in safe moving and handling procedures despite the need for lifting and moving people being minimal at present. The fire logbook was all in order and evidenced that all the necessary checks had been completed and staff have received instruction and are aware of fire safety procedures. All maintenance contracts were up to date. Any accidents that happen are followed up and where necessary, strategies are put in place to prevent a reoccurrence DS0000026643.V364650.R01.S.doc Version 5.2 Page 22 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 4 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 4 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 3 3 X 3 3 X DS0000026643.V364650.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000026643.V364650.R01.S.doc Version 5.2 Page 24 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. 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