Care Home: Thames House

Similar services:

• Sunny Bank (P.R.S.) Ltd
• Ruskin Lodge
• Ashwood Court Unit 1
• Dystlegh Grange
• Thornton Lodge
• The Good Companions
• Springfield Cottage
• Cuerden Grange Rest Home

What the care home does well Thames House presents with a very warm, caring and friendly environment and residents appeared relaxed and comfortable with the staff. It was evident through interviews, general observations and discussions that staff had a good knowledge of the residents` individual care needs and the level of support required. During our visit staff were observed spending a great deal of time with residents, either on an individual basis or within a group. Care was seen to be given in a discreet, sensitive manner and staff were patient and gentle in their approach.Feedback from residents was very good, comments regarding the service included: "just ask the staff they are always there"; "Staff are excellent" and "The care is really good and I feel really safe here". Prior to admission the manager assesses residents` health and social needs. Information collected is then used to form the basis for the plan of care. Assessment documentation seen had been completed to a good standard and included key areas regarding the residents` health and general well being. Care files were organised, the information easy to read and care plans identified the relevant care and support required. Attention is paid to recording basic needs such as dental, optical, hearing and foot care. Lots of different types of activities were arranged, both in the home and out in the community. The physical accommodation is of a good standard, with appropriate aids and adaptations available for the residents. The home has an experienced and enthusiastic team of staff who work well together and enjoy taking part in training and development sessions. The staff are motivated and keen to ensure that residents receive high standards of care. Seven staff returned our surveys and comments included were: "The home gives good training"; "The home looks after the residents well" and "Provide excellent individual care for each resident". The manager was experienced and ran the home well. She made sure she checked out staff before they started working at the home and gave them training and support to make sure they did the job to the best of their ability. The manager communicates a clear sense of direction, is able to evidence a sound understanding and application of `best practice`, particularly in relation to continuous improvement, resident satisfaction and quality assurance. What has improved since the last inspection? Both of the recommendations made at our last visit have been met. A new application form has been devised to ensure that the manager obtains all of an applicant`s work history before being considered for a job in the home. CARE HOME ADULTS 18-65 Thames House Thames Street Rochdale Lancs OL16 5NY Lead Inspector Bernard Tracey Unannounced Inspection 8th May 2008 09:00 Thames House DS0000068666.V363626.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 Thames House DS0000068666.V363626.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. Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thames House Address Thames Street Rochdale Lancs OL16 5NY 01706 751840 01706 713366 thames@exemplarhc.com 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) Thames Health Care Ltd Christine Anne Taylor Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Physical disability (20) of places Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 20 service users to include: *Up to 20 service users in the category of PD (Physical disability under 65 years of age); *Up to 10 service users in the category of MD (Mental disorder excluding learning disability and dementia). The 10 places for service users with a mental disorder must only be used for persons suffering from Huntingdon’s disease. 25th May 2007 2. Date of last inspection Brief Description of the Service: Thames House is a purpose built, specialist provision for people with Huntingdon’s disease. The building is nominally split into two units, one on each floor. Each unit has its own lounges and dinning room. All bedrooms are single and include ensuite facilities. There is ample provision of aids and adaptations for people with restricted mobility. A sensory bathroom is also available. Thames House is located in Rochdale. Fees for the service are negotiated on an individual basis. Thames House DS0000068666.V363626.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 stars. This means the people who use this service experience excellent quality outcomes. We (the Commission of Social Care Inspection) undertook a key inspection, which included an unannounced visit to the home. The staff at the home did not know the visit was going to take place. The manager was asked to fill in a questionnaire, called an Annual Quality Assurance Assessment (AQAA), telling us what they thought they did well, what they need to do better and what they have improved upon. Where appropriate, these comments have been included in the report. Comment cards were received from five residents and seven members of staff. At the time of our visit there were 12 residents living in the home. We spent six hours at the home over one day. During this time, we looked at care and medicine records to ensure that health and care needs were met and also studied how information was given to people before they decided to move into the home. A tour of the building was undertaken and time was spent looking at records regarding safety in the home. We also examined files that contained information about how the staff were recruited for their jobs, as well as records about staff training. We spent time speaking to three residents, as well as speaking to four staff, the manager and the Clinical Team leader. We have not received any complaints about the service since our last Inspection. What the service does well: Thames House presents with a very warm, caring and friendly environment and residents appeared relaxed and comfortable with the staff. It was evident through interviews, general observations and discussions that staff had a good knowledge of the residents’ individual care needs and the level of support required. During our visit staff were observed spending a great deal of time with residents, either on an individual basis or within a group. Care was seen to be given in a discreet, sensitive manner and staff were patient and gentle in their approach. Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 6 Feedback from residents was very good, comments regarding the service included: just ask the staff they are always there; “Staff are excellent” and “The care is really good and I feel really safe here”. Prior to admission the manager assesses residents’ health and social needs. Information collected is then used to form the basis for the plan of care. Assessment documentation seen had been completed to a good standard and included key areas regarding the residents’ health and general well being. Care files were organised, the information easy to read and care plans identified the relevant care and support required. Attention is paid to recording basic needs such as dental, optical, hearing and foot care. Lots of different types of activities were arranged, both in the home and out in the community. The physical accommodation is of a good standard, with appropriate aids and adaptations available for the residents. The home has an experienced and enthusiastic team of staff who work well together and enjoy taking part in training and development sessions. The staff are motivated and keen to ensure that residents receive high standards of care. Seven staff returned our surveys and comments included were: “The home gives good training”; “The home looks after the residents well” and “Provide excellent individual care for each resident”. The manager was experienced and ran the home well. She made sure she checked out staff before they started working at the home and gave them training and support to make sure they did the job to the best of their ability. The manager communicates a clear sense of direction, is able to evidence a sound understanding and application of ‘best practice’, particularly in relation to continuous improvement, resident satisfaction and quality assurance. What has improved since the last inspection? What they could do better: No requirements or recommendations have been made. Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 7 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. Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 8 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 Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Detailed assessments are undertaken before people come into to the home and sufficient information is provided so they can feel confident that their needs can be met. EVIDENCE: Feedback from our discussion with residents indicated that the majority felt they had been given sufficient information about the home prior to moving in, including an opportunity to look round the home before making the decision. Comments received included: “Its brilliant here - like a 5 star hotel”; “When I first seen this home I fell in love with it” and “I was just sent here by my social worker”. In the completed Annual Quality Assurance Assessment the manager told us that each service user is provided with a statement of purpose and a service user guide, visits to the home were organised and transport provided if required, overnight stays were encouraged. Admissions are planned and range from short visits to trial placement depending on the needs and wishes of the person. Each service user is issued with a contract, which covers the home’s values, key principles and expectations of the service user including care and support. Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 10 Two residents both said it was helpful to meet someone from the home before they moved in. Before any resident was admitted to the home, an assessment of their needs was undertaken by a senior member of the staff from the home and from the professional, i.e., care manager, requesting their admission. Assessments we examined on file supported this. The files showed that care management assessments had been completed by social workers. Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People living at the home are provided with information enabling them to make decisions about activities of daily living. EVIDENCE: The care plans we looked at are extremely informative, enabling the care staff to identify with residents’ specific care needs, together with their preferences, likes and dislikes. All health, social and emotional care needs are identified and individual care plans are prepared for each of the identified need. The care plans are signed by the resident to confirm agreement with them. Residents spoken to on the day of the inspection confirmed that they had discussed the care plans with the manager or nurse and were able to discuss their preferences in relation to meals, times of going to bed and getting up and how they liked things done. Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 12 Residents have choice over their personal care and are encouraged to be independent and responsible for their own personal hygiene where possible. Risk assessments are undertaken on all residents in relation to daily living and appropriate measures are put in place to reduce or remove any potential risk. These are recorded in the care files. Residents felt they were treated with respect and in a dignified manner at all times. Privacy is respected at all times. Residents are free to meet with their visitors in the privacy of their own bedroom or in one of the communal areas. Residents spoke highly of the manager, the care and ancillary staff and commented on how committed and caring they were. Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Residents are able to enjoy a full and stimulating lifestyle with a variety of opportunities to choose from. Staff are skilled at promoting choice and control in residents’ lives. EVIDENCE: The range of leisure activities available in the home was varied, reflecting the diversity of residents and their social, intellectual and physical capacities. The home has a dedicated activity co-ordinator who organise events and activities within the home, as well as trips out to various places of interest. The programme of activities was displayed in the reception area and in other strategic places throughout the home, so that residents were aware of what was ‘going on’. Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 14 We met with the activity co-ordinator during our visit to the home. He informed us that activities were also detailed in the monthly newsletter, a copy of which was given to each resident. He has sought the views of residents and considered their varied interests and abilities when planning the routines of daily living and arranging activities. Routines are very flexible and residents can make choices in major areas of their life. The routines, activities and plans are resident focussed, regularly reviewed and can be quickly changed to meet individual residents’ needs. Each resident has their own activities and interest assessment completed and their interests are recorded and a programme agreed to reflect their personal preferences. Links with the community were good and valued the role which relatives and friends continued to play in the lives of residents. Residents benefited from being able to exercise choice and control over their lives. The manager and staff are aware of promoting equality and diversity and encourage the residents to develop a lifestyle and interests that are individual to them. Some residents choose to take part in group activities, such as going for bar meals, walks, bowling, or choose to go on holiday with other residents within the home, while others have chosen to pursue their own interests such as canoeing. Residents we spoke to said they enjoyed the food and that they receive enough to eat and drink. We observed staff being attentive during the lunchtime period, asking if people had finished their meal before they removed their plate, asking if they wished for some more and offering a choice of starter, main meal and dessert. The dining tables were set appropriately – tablecloths, cutlery, serviettes and jugs of water. Staff were observed assisting the residents during mealtimes in a discreet way but ensuring each person was able to enjoy food of their choice. Staff carried out their care and support duties in a way that enables residents to maintain choice and control over their daily lives wherever possible. Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 15 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 excellent. This judgement has been made using available evidence, including a visit to this service. Residents are supported by the staff and relevant health care professionals to ensure that their emotional, physical and personal care needs are met. Staff ensure that care is person led, personal support is flexible, consistent and is able to meet the changing needs of the residents. Staff respect people’s preferences and have expert knowledge about individual personal needs when providing support. EVIDENCE: Individual care plans are in place for each resident. The plan sets out how the current and anticipated needs are to be met. We looked at two care plans in detail. All care plans and risk assessments are reviewed on a regular basis, or as changes in care needs are identified, and these are updated as appropriate. Staff actively promote the residents’ right of access to the health and remedial services that they need, both within the home and in the community. Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 16 Regular appointments are seen as important and there are systems in place to make sure appointments are not missed. Records show that the home arranges for health professionals to visit frail residents in the home and provides facilities to carry out treatment. Records held in the home provide evidence of the input by other healthcare professionals and advice is sought from the Dietitian and the Tissue Viability Specialist Nurse as necessary. The manager was able to describe how residents and their relatives are involved in the drawing up of the care plan and understood the meaning of a care plan to describe the assessed needs of a resident and how the needs were to be met. The care plan would also include any changes in the resident’s condition. Signatures in the care plans, indicating that the individual agreed with the plan and any alterations made to it after consultation with the individual, confirmed this involvement. The care plan is generated from the single care management assessment and the assessment provided by the home. The plan sets out how the current and anticipated needs are to be met. There is evidence that the resident together with family, friends or advocate are involved in the drawing up of the plan. Any potential restrictions on choice, freedom, services or facilities that become part of the resident’s daily life, had been discussed and agreed with the resident during assessment and recorded in the care plan. Two residents spoken with confirmed that they had been given “all the information about how the home is run before coming in the place.” One resident said he had “come on a trial basis and decided to stay”. The home has a robust medications policy and inspection of the medications records provide evidence that the staff follow the procedure. All records relating to medications were found to be well maintained and up to date. The medications room and trolley were seen to be clean and organised. Appropriate arrangements are in place for the disposal of unwanted medications through a contract with a disposal company. At the time of our visit no individual resident was managing their own medication. Wherever possible, residents are encouraged to manage their own finances and, at the time of the inspection, most residents were taking personal control over their money, but where the home does manage the finances for individuals, records are maintained and a recognised tool for audit is incorporated in the monthly review of finance supplied to the Registered Provider by the home’s administrator. Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 17 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. Residents were confident that complaints would be listened to, taken seriously and acted upon. Appropriate systems were in place to protect residents from abuse. EVIDENCE: A clear, detailed formal complaints procedure is displayed in the reception area of the home and provided to each resident, supporting the home’s open culture, where residents were encouraged to express their views informally and in the regular residents’ meetings. Residents felt staff listened to them and they knew who to talk to if they were unhappy or had any concerns. A resident stated “It would be hard to complain about anything here - the place is good”. The Commission for Social Care Inspection has received no complaints about the home since the last inspection. Abuse awareness training was provided to all new starters, with annual updates. Staff understood the importance of listening to residents’ concerns and how to respond to any issues that were raised. Thames House DS0000068666.V363626.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 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. The standard of furnishing and fittings within the home provide a homely, clean and comfortable environment for residents to live in. EVIDENCE: Thames House is a purpose built home that is situated on a residential estate off the main road near to Rochdale town centre. The home is set in its own grounds with a private enclosed garden space at the rear. The home is well maintained both internally and externally. During this visit a tour of the building was undertaken. The accommodation is spacious, homely and divided into two units; one on the first floor and one on the ground floor. Both units have two lounges a dining room, bathroom and toilets, as well residents’ own rooms. The home has appropriate aids and adaptations for people with a physical disability. This included dining-room tables which could be raised or lowered to easily facilitate people using wheelchairs. Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 19 Bathrooms are domestic in style and tastefully decorated to enhance a relaxed atmosphere when bathing and are further equipped with lighting and sound systems, which can be controlled by residents when in the bath. Bedrooms were nicely decorated and the residents had brought their own personal possessions, personal photographs. One told us, he liked his room and he had everything he needed. The home has domestic and kitchen staff that carry out the cooking and cleaning. We found the home smelt fresh and was very clean and tidy. Residents confirmed this was usual. Thames House DS0000068666.V363626.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. The staff team had collective skills training and expertise to undertake their roles effectively and good recruitment and selection procedures were in place to ensure that the residents were protected. EVIDENCE: Three staff files were viewed with regard to recruitment practices and these contained all of the necessary checks to protect the residents. Staff had completed a job application form and two references had been obtained. Staff files contained a POVA (Protection of Vulnerable Adult) check and CRB (Criminal Record Bureau) disclosure at enhanced level. The necessary checks are in place prior to staff commencing work and the interviewer completes an interview checklist. Staff are given a health declaration form to complete and a contract of employment. Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 21 Computerised, individual staff training records provided a clear summary of both induction and ongoing training. This was extensive and wide ranging, with mandatory courses, i.e., moving and handling, medication, fire safety, and first aid. Specialist training included care planning, risk assessment, mental health, suicide and self-harm and challenging behaviour. This training package was confirmed by the manager and was identified in the written AQAA she had provided us with. Similarly, staff who were interviewed confirmed that training was available, that they were encouraged to attend and that it gave them appropriate competencies to meet the needs of the residents. A staff member commented, “the training is excellent here”. Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Residents benefit from living in a well-run home where their safety and welfare are promoted and protected. EVIDENCE: The manager has the required qualifications and experience, and is competent to run the home. There is a strong emphasis of being open and transparent in all areas of running of the home. The manager and staff work hard to maintain a culture, where everyone feels they are included in decision-making and feel valued as an individual. Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 23 There is a good system in place to gather staff, residents and relatives’ views through regular meetings and satisfaction questionnaires as part of the monitoring of quality. Staff spoken to had a clear understanding of their role and what was expected of them. Documentation was examined that confirmed that staff received regular supervision and annual appraisal. Residents and visiting professionals spoke well of the management team and the care and support that they give. The inspector was able to witness their approach to the residents and staff and confirm the comments made. Information provided by the manager in the AQAA and examination of the records, confirmed that all safety equipment is regularly serviced. The policies and procedures in the home ensure that the health, safety and welfare of the residents and staff are promoted and protected. Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 x 4 X 4 X X 3 X Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 25 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 Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local Office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 Thames House DS0000068666.V363626.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!