Care Home: The Shelley

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What the care home does well The Shelley provides a very high standard of accommodation for the people who live there and all communal areas and private bedrooms are decorated and furnished to an exceptional standard.To ensure that people`s individual needs can be met, the home carries out detailed pre-admission assessments and care plans so that the staff team have the information they need to provide a personalised service for each person. The home works well with other healthcare professionals and provides a monthly consultation with a local doctor for advice and support. The home is to be commended on the variety and quality of activities, outings and opportunities being provided for the people who live there and people tell us that they have a wide choice of fresh home cooked meals, served in a "restaurant" self service fashion. People are supported to maintain their independence and tell us that they are treated in a respectful and supportive manner. Service users, families and other healthcare professionals say that the staff team are professional, respectful and friendly and that the home is managed by a competent and caring manager in a way that respects people`s privacy and dignity. In order to ensure the safety of people the home carried out robust recruitment procedures and the staff team are well trained and well supported Comments about the home from a family member included " The Shelley meets all of my mother`s needs from encouraging her to have her own decoration and furniture, her independence (she loves dusting and tidying) to her health needs, individual diet and need for love and companionship". What has improved since the last inspection? The home continues to provide a responsive and individualised service for the people who live there and responds to suggestions by service users and families to ensure a continuous improvement to the service being provided. The number of the room to be occupied has now been added to the terms and conditions of residency. What the care home could do better: The Shelley is providing an excellent service and there are processes in place to ensure and monitor a programme of continuous improvement. CARE HOMES FOR OLDER PEOPLE The Shelley 54 Shelley Road Worthing West Sussex BN11 4BX Lead Inspector Annie Taggart Unannounced Inspection 25th February 2008 09:30 X10015.doc Version 1.40 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 The Shelley DS0000065564.V358921.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 Older People. 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. The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Shelley Address 54 Shelley Road Worthing West Sussex BN11 4BX 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) 01903 237000 F/P 01903 237000 info@theshelley.com The Shelley Ltd Mrs Marlene Yvonne Sanders Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No more than 32 service users to be admitted. No service users under the age of 65 to be admitted. Date of last inspection 8th May 2006 Brief Description of the Service: The Shelley is registered as a care home for older persons (over the age of 65). It is situated in a residential area on the west side of Worthing, close to local bus and trains services. There are shops within a few hundred yards. The accommodation is provided on ground and first floor levels, and there is a passenger lift. All bedrooms have en-suite facilities, and a number of bedrooms also have kitchen facilities. The service is run by The Shelley Ltd, for whom the responsible individual is Mrs Marlene Sanders. Mrs Sanders is also the Registered Manager. Current fees are £385 to £585 per week and any extra charges are detailed in the information about the home The Shelley DS0000065564.V358921.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. In order to prepare for the visit, surveys were sent to service user, families and professionals involved with the home. Six service user, five family and two processional people returned the surveys and all made very positive comments about the facilities and care being provided in the home An Annual Quality Assurance (AQAA) had been completed by the home for the last key inspection visit and information from this and the last inspection report was also used to inform this visit. The unannounced visit was carried out at 9.30am on Monday 25th February and lasted for five hours. During the visit we spent time with the people living in the home, both in their private bedrooms and in communal areas and we spoke to the staff on duty and observed staff practice. We were also able to speak to two family members and a hairdresser who were visiting the home. Four care plans and all supporting documentation such as daily records were looked at and we also looked at four staff records and the system for the recording and administration of medication. We looked at menus and food records, saw the main meal of the day being prepared and served and we received very positive feedback from service users about the quality and choice of meals being provided. Records for the running of the business including the quality assurance process, health and safety, staff fire training and incident and accident recording were also seen. Feedback was given to the Registered Manager, Mrs Sanders following the visit. What the service does well: The Shelley provides a very high standard of accommodation for the people who live there and all communal areas and private bedrooms are decorated and furnished to an exceptional standard. The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 6 To ensure that people’s individual needs can be met, the home carries out detailed pre-admission assessments and care plans so that the staff team have the information they need to provide a personalised service for each person. The home works well with other healthcare professionals and provides a monthly consultation with a local doctor for advice and support. The home is to be commended on the variety and quality of activities, outings and opportunities being provided for the people who live there and people tell us that they have a wide choice of fresh home cooked meals, served in a “restaurant” self service fashion. People are supported to maintain their independence and tell us that they are treated in a respectful and supportive manner. Service users, families and other healthcare professionals say that the staff team are professional, respectful and friendly and that the home is managed by a competent and caring manager in a way that respects people’s privacy and dignity. In order to ensure the safety of people the home carried out robust recruitment procedures and the staff team are well trained and well supported Comments about the home from a family member included The Shelley meets all of my mothers needs from encouraging her to have her own decoration and furniture, her independence (she loves dusting and tidying) to her health needs, individual diet and need for love and companionship. What has improved since the last inspection? What they could do better: The Shelley is providing an excellent service and there are processes in place to ensure and monitor a programme of continuous improvement. The Shelley DS0000065564.V358921.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. The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 3 5 and 5 Outcomes for service users in this area are Excellent. This judgement has been made using available evidence including a visit to this service. Prospective service users and their families can be confident that they will be given good information about the home, that their needs and wishes will be assessed and recorded and contracts of terms and conditions of residency agreed. EVIDENCE: The Shelley provides detailed and comprehensive information about the service on offer. There is a brochure, Statement of Purpose and Service User Guide that includes photographs of areas of the home and also comments from current service users and their families. People are also given a “Choosing Care” checklist produced by the home in order to assist them to ensure that their needs can be met. The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 10 As the home clearly states that it caters for people with low dependency needs, prospective service users and their families are encouraged to visit the home and short stays can be arranged to “test drive” the facilities on offer. Several people currently living in the home told us that they had originally come in to the home for a short break or respite and had been so impressed that they had decided to stay. In order to ensure that the home can meet people’s individual needs, preadmission assessments are carried out and recorded and those seen during the visit, contained detailed information about both healthcare and social need and wishes. People are given a welcome pack when they are admitted and this details all of the services on offer. Contracts of terms and conditions of residency are agreed and those that we saw included the room to be occupied, the fee to be paid and had been signed by service users. When the home can no longer meet people’s needs for example due to increased healthcare needs, they are supported to find another suitable home and are assisted in this by the manager having produced a brochure of other care homes and nursing homes in the area. Intermediate care is not provided by the home. The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 Outcomes for service users in this area are excellent. This judgement has been made using available evidence including a visit to this service. In order to ensure that people have a high level of care and support, very comprehensive and detailed care plans are in place that are regularly reviewed and updated. People have access to healthcare professionals on a regular basis and medication is well managed. EVIDENCE: For each person living in the home there is a comprehensive plan of care in place, which gives the staff team detailed information about both the social and healthcare needs of the people they are supporting. We tracked the care plans for four of the people currently living in the home and all contained background information, preferred routines and preferences, risk assessments that are outcome focussed to assist people to be as independent as possible and details of people’s hobbies and interests. The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 12 There are detailed daily care guidelines in place for the staff team to follow, that show how people wish to be supported with both personal and healthcare needs and daily records show that the home works with a variety of healthcare professionals including local surgeries and district nurses. There is a monthly “ Wellbeing” clinic held in the home and a local doctor speaks with service users about any healthcare concerns they might have and recently a Nutritionalist visited the home and spoke at the resident’s meeting about healthy eating. In a survey the doctor said, “ the home provides good accommodation, good food and kindness and a high level of personal care is offered where required. For the home to have decided to have a regular doctor advice session monthly seems to be very popular with residents and I am proud to be of help to people in this home. Comments from service user included, “ I am looked after very well indeed, we have very good surgeries and the staff are very attentive if you are unwell” and “ I am very comfortable here, if I am not feeling too good the staff pop in all the time to make sure I am o.k., they will get the doctor for me and let my family know”. The home has a trained occupational therapist on the staff team who ensures that people have the aids and adaptations they need in order to support their mobility and safety. Daily records are completed for each person and full monthly reviews are completed and recorded with any changes needed made to the care plans. The home has an agreement with a local pharmacy and a monitored dose system is in place. Medication is securely stored in a well organised manner and records were current and in good order. There are detailed guidelines to assist the staff team to identlfy what medications they are administering, what the medication is for and what side effects they might cause. Staff receive training in the administration of medication and we saw their records on file in the home. For people who wish to self medicate, there are risk assesments and signed agreements in place and people are provided with lockable cabinets in their rooms. The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 1 3 14 and 15 Outcomes for service users in this area are excellent. This judgement has been made using available evidence including a visit to this service. The home provides a wide range of outings and entertainment opportunities and also supports people’s individual hobbies and interests. A good choice and high standard of meals are provided and people are supported to keep their independence. EVIDENCE: Assessments and care plans show that the ethos of the home is to promote as independent a lifestyle as possible for the people who live there and for individual lifestyle choices to be respected and met. The home is to be commended on the quality of activities and outings it provides and a day care coordinator is employed for eight hours a day, five days a week including some week ends. Activities include outside entertainers, card games, quizzes and craft sessions, some people have formed a lunch club and told us that they like to visit local The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 14 cafes and restaurants and there are also visits to cinemas, the ballet, areas of local interest and people are also supported to follow their religious beliefs. People told us that the activities person is very flexible and will take them out shopping or to appointments in the car and the home also regularly hires a bus for longer outings. A hairdresser visits weekly and manicures and aromatherapy sessions can also be arranged. Several people told us that they had recently enjoyed a visit to see some windmills and for tea out and the manager said that as the home was so near the sea they were going to hire a beach hut for the Summer. Some people living in the home drive their own cars or access the local community using their mobility buggies. A computer is available for the use of service users and several people attend lessons provided by the home and use the Internet to shop and keep in touch with family and friends. People also said that they enjoyed looking after the home’s two cats and also enjoy the owner’s dog that visits most days. During the visit people were reading, playing cards, going out shopping, the hairdresser was attending to people and visitors were being welcomed. Menus and food records show that a variety of fresh, home cooked meals are provided and this includes the choice of a cooked breakfast, several choices at lunch and also a cooked supper. All of the people we spoke with were very complimentary about the choice and quality of the meals on offer and one person commented, “ This is such a good place, they pay particular attention to your food requirements and adapt the menu to suit your needs, I particularly like that sherry is provided before lunch and you can have wine with your meal. Also the vegetables are in serving dishes and you can help yourself. If you are out they will keep a meal for you and will also serve meals in your room if you wish”. Some of the people living in the home had said that they wished to be more independent and had requested small kitchen areas to be added to their rooms. This has been done and people say they enjoy making their own breakfast and snacks and are supported to go food shopping by the day care person or staff. The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Outcomes for service users in this area are excellent. This judgement has been made using available evidence including a visit to this service. The people living in the home can be confident that their concerns and complaints will be recorded and acted upon as soon as possible and that staff awareness of the protection of vulnerable adults is a high priority within the home. EVIDENCE: There is an accessible complaints procedure in place, a copy of which is given to each service user in the welcome pack provided by the home. The complaints book shows that all complaints are taken seriously, recorded and acted upon as soon as possible. A family member said that they felt there was nothing at all to complain about but if they did have concerns they were sure that the manager Mrs. Sanders would deal with it immediately. A service user said, “ you only have to mention something and it is dealt with straight away, the staff are so kind here and only want the best for you”. Regular resident’s meetings are held and the minutes show that concerns and suggestions for improvements to the service are recorded and acted upon. The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 16 Records show us that the staff team all attend training in the protection of vulnerable adults from abuse and the home has also produced a handbook for each staff member detailing the recognition and prevention of abuse. The manager also told us that abuse awareness is discussed in training sessions that are held for staff every Thursday. The staff members that were on duty were aware of their responsibilities and said that they would report any suspected abuse straight away. The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 22 24 and 26 Outcomes for service users in this area are excellent. This judgement has been made using available evidence including a visit to this service. The Shelley provides an exceptional standard of environmental facilities for the people who live there. People are given a choice of furnishings and fittings and the home is very clean, safe and hygienic. EVIDENCE: The Shelley provides and exceptional standard of accommodation and a wide range of facilities for the people who live there. All communal areas are decorated and furnished to a very high standard with quality furnishings and fittings but at the same time the environment is welcoming, friendly and homely. The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 18 The large lounge has a “café” area with a coffee machine where people can make drinks for themselves and their visitors at any time and the dining room is large, light and airy with quality furniture and fittings in place. There is an attractive rear garden with seats, tables and sun umbrellas and several people said that they enjoy either sitting or working in the garden in better weather. Private bedrooms are also large, light and airy with ensuite facilities and are decorated and fitted to a very high standard. Service users said that they could bring their own furniture and belongings with them if they wished and also said that they had a choice in the colour and furnishings in their rooms. Twenty of the bedrooms are more like small flats having a large lounge area, separate bedroom and large ensuite facilities and as already noted some people have small kitchen areas. Bedroom doors have all been fitted with automatic fire closures so that people can leave their doors open safely if they wish to do so and the home was very clean and hygienic throughout. Comments from service users included, “ because the rooms are so large I could bring all of my belongings, books and bookcases, which is very important to me and I am very comfortable indeed”. Another person said. “ I have lived in two care homes before but this home is exceptional and we are very pampered. It is not institutionalised at all, we decide on our routines and come and go as we please. The environment is beautiful but it is still very homely and the choice and quality of food is outstanding. The manager and staff go out of their way to make sure you have anything you need and we have celebrations like Valentines Day, with chocolates and heart shaped balloons and Chinese New year when the dining room is decorated. Parking is available for people’s cars and mobility buggies can be safely stored in the large garage. The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 and 30 Outcomes for service users in this area are excellent. This judgement has been made using available evidence including a visit to this service. A competent, caring and very well trained staff team supports the people living in the home. To ensure that people are protected a robust recruitment process is carried out, the majority of the staff team hold a care qualification and all staff receive regular supervision and support EVIDENCE: Staffing rotas show us that in order to provide a responsive and individualised service, the manager ensures that there is a high ratio of staff to service users. There were five care staff plus the deputy manager, one chef and a kitchen assistant, three cleaners and a maintenance person and five days a week there is a day care coordinator. The Registered manager also works in the home on a daily basis and is extra to the rota. The people living in the home spoke very highly of the staff team and comments included, “ the staff here are extremely helpful and tactful, they are not intrusive at all but are there at the press of a bell” and from a survey, “ the staff are always caring efficient and courteous and the special individual treatment we get shows that the manager will go to any lengths to meet our needs”. The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 20 To ensure the protection of service users the home follows a robust recruitment process, we saw the records for four staff and all contained the required documentation including references and a current Criminal Bureau Check (CRB). The manager told us that recruiting the people with the correct skills to meet the ethos of the home and provide an individualised service had not been an easy task but that the home had clearly identified what skills they required and had detailed this in the job description. All new staff members receive a structured induction in line with Skills for Care guidelines and receive good support and training opportunities. Records show us that courses attended include all mandatory training, medication management, abuse awareness, continence management, nutrition awareness and counselling skills. All of the staff team either have the National Vocational Qualification in Care (NVQ) or are working towards the award and in the AQAA the manager told us that over 80 of the staff team current hold the qualification. Records show us that five staff have NVQ 4, six have NVQ 3 and the deputy manager has NVQ 4 and the Registered Manager’s Award. Records also show us that regular supervision sessions and staff meetings are held and we saw the notes kept on file in the home. For staff members who do not have English as their first language, communication classes have been provided and observation during the day showed us that all of the staff on duty communicated well with service users in a friendly and respectful manner. The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 37 and 38 Outcomes for service users in this area are excellent. This judgement has been made using available evidence including a visit to this service. The Registered Manager sets very high standards in the home and supports the staff team to achieve this. Records are current and in good order, regular quality assurance processes are followed in order to improve the service on offer and there is a high commitment to health and safety awareness. EVIDENCE: The home is managed by the owner Mrs. Sanders, who has skills, qualifications and previous experience in managing care homes. Mrs Sanders is an Registered Nurse has NVQ 4 in Care and the Registered Manager’s Award and records showed us that she and the deputy manager attend a wide variety of courses and seminars in management and care issues The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 22 in order to improve their skills and knowledge and keep up to date with current trends in the care field. Service users, staff, professionals and families spoke very highly of Mrs. Sanders commitment to providing a very high standard of care and described her as being very professional, open and inclusive. Comment included, from staff members, “information sharing is excellent in this home and the manager is always present to guide and support and we have a lot of staff on duty, which gives us plenty of time to engage meaningfully with residents” and “ enough staff are always available but if something unpredicatable happens, then cover will be found as soon as possible and the manager and senior members of staff are always on call in times of need”. A family member said, “ this home is amazing, the manager is very professional but friendly and approachable and the atmosphere is lovely. The manager keeps us informed about our relative and we cannot fault anything”. There is an ongoing programme of quality assurance checks being carried out in the home, which starts with a suggestion box where people can suggest improvements and give feedback, monthly resident’s meetings, six monthly audits and a full annual quality audit based on National Care Standard requirements.Surveys are also sent to service users, families and professionals and outcomes are used to improve the service on offer. We saw the records for the last annual quality checks and also a large number of cards and letters making positive remarks and compliments about the standard of care being provided in the home. There are very clear policies and procedures for staff to follow and records show us that regular maintainance checks are carried out and that staff receive fire training. Accidents and incidents are recorded and action taken to minimise risks. Health and safety issues are addressed and all members of staff are given a health and safety handbook produced by the home which details their responsibilities to keep the workplace safe and how to identify and report any areas of risk in the home. Mrs Sanders told us that their was a financial and future development plan in place and this includes planning permission being sought to extend the home. The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 X 4 4 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 4 X 4 X 4 X 4 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 4 X 4 4 The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 24 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 The Shelley DS0000065564.V358921.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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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