Care Home: Woodview Care Home

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What the care home does well The people who wish to use the service and their representatives have the information needed to make an informed decision as to whether the service is able to meet their needs. One of the care staff said, "Often the residents were unable to let us know their needs. But their relatives and care managers help us." Two sets of family members said the following. "We have been to several service settings and found this the most suitable and we are happy that our X receives the most needed care here." "The staff inform us when they have problems and if they felt that they are unable to meet certain needs. They keep us informed and we are very happy." Another relative said, "There is no pressure for us to keep X in the home. Part of the plan is to find out how best to make X independent. This could be X moving into an independent setting. The staff were seen helping people understand and make decisions by using different methods of communications. They used some pictures, objects that the people were familiar with and able to relate to, verbal communication and also recognise the individual body language. The Expert by Experience made the following comments. "All of the residents we met had communication impairments with very little verbal speech. I found out that staff use BSL level 1, picture boards and easy read documents to communicate with residents. I also found out that speech therapists visit the residents at the home." People who use services are able to make choices about their life style, and they are supported to develop their life skills by the staff. Social, educational, cultural and recreational activities are varied and meet the individual`s expectations. The Expert by Experience made the following statement. "Residents can take part in in-house activities and out-house activities. Activities are co-ordinated by staff and residents can decide if they wish to take part." We interacted with the five people using the service; we spoke with the staff and checked the care plans including daily progress of the people living at the home. It was evident that the staff were sensitive and flexible when supporting and delivering care. The staff worked towards maintaining privacy, dignity and independence of those living at the home. When we toured the home, the deputy manager knocked on the doors before entering the rooms. The Expert by Experience and the support manager toured the premise with the deputy manager later on in the day. These were their comments. "I found the home was welcoming and very neat and tidy. We first looked in the large living room where one resident was watching TV and another was sitting on the floor. We then looked into the large dinning room where several staff members and residents were sat. All the bedrooms were decorated to each residents taste and they even had their own furniture in the room." The supplying pharmacist had carried out regular audits of medication management and the staff had complied with the recommendations. Three Medication Administration Sheets were checked against the medication supplied and prescribed. They were satisfactory. The manager and the staff said that staff were following a distance learning course on safe handling of medication. One relative made this comment. "Senior carers have a good understanding about the conditions and they have experience and knowledge about their clients to know when to inform the doctor." There was a clear complaints procedure, which was accessible to the visitors. DS0000065605.V349813.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? All staff have had training in Protection Of Vulnerable Adults. The staff were able to explain what abuse was and how they go about preventing and reporting abusive incidents. We were then shown to the Hydrotherapy swimming pool, which I found out, was very warm water. The member of staff told me that all staff now have their lifesavers certificates and the pool attendant is also a fully trained physiotherapist. I was concerned that as the pool is hired out by other users this may affect the safety of the residents. The staff are trained, skilled and in sufficient numbers to support the people who occupy the home. They contribute to the smooth running of the service. The management and administration of the home is based on openness, respect and includes the people and their families in the running of the home. The present management promotes a good standard of care and support and follows this by regular monitoring and making improvements based on the findings. The present staff group and the Responsible Individual are committed to providing a good service. Therefore people living at the home receive a good standard of care. CARE HOME ADULTS 18-65 Woodview Care Home Richmond Parkway Richmond Park Sheffield South Yorkshire S13 8HH Lead Inspector Marina Warwicker Key Unannounced Inspection 5th December 2007 11:00 DS0000065605.V349813.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 DS0000065605.V349813.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. DS0000065605.V349813.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodview Care Home Address Richmond Parkway Richmond Park Sheffield South Yorkshire S13 8HH 07908 927022 none none None United Health Plc 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) Vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places DS0000065605.V349813.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2006 Brief Description of the Service: Woodview Care Home is a purpose built service, which provides personal care to adults with learning difficulties. The home consists of eight bedrooms, a lounge, a dining/activity area and a private and secure patio area to the rear. It is situated in the Woodhouse area of Sheffield and it is near amenities such as public transport, local shops and daycentres. The home was registered with the Commission for Social Care Inspection in January 2006. The people using the service have access to a mini bus supplied by the home. The weekly charges range between £1,700 and £1,950. The people occupying the home receive either one or two staff attending to their needs as part of their care package. The people pay for their own toiletries, books, magazines, chiropody and hairdressing with their personal allowances. There is a hydrotherapy unit adjacent to the home and people at the home are able to access it. Each bedroom has special tracker systems – i.e. special hoists- if they require moving from their bedroom to the bathroom. There is information about the service at the entrance hall for the relatives and visitors. There is a visitor’s car park to the front of the building. DS0000065605.V349813.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspection was carried out without any prior arrangement with the management of the home on Thursday 5th December 2007 between 11.00 am and 5.00 pm. Residents and relatives were consulted and the staff on duty were spoken with. We also forwarded three relative’s, four health & social care professionals and ten staff surveys to obtain feedback about the service. Comments received from the surveys up to the date of the site visit were shared with the manager. An Expert by Experience (i.e. an individual who has had experience in this care setting) and his supporting manager joined us at the site visit. They spent time looking around the home, interacting with the people living at the home and chatting to staff. Their observations were shared with the manager and have been included in this report. We also spent time observing and interacting with staff and the people using the service. The premise was inspected which included bedrooms of service users and the communal areas inside and outdoors. Samples of records were checked. They were medication records, care plans, staff recruitment and training files. I would like to thank the people living at Woodview Care Home, their relatives, the expert by experience, his supporting manager, the staff at the home and the management for their contribution towards the findings in this report. This report has also been produced in the Easy Read format. What the service does well: The people who wish to use the service and their representatives have the information needed to make an informed decision as to whether the service is able to meet their needs. One of the care staff said, “Often the residents were unable to let us know their needs. But their relatives and care managers help us.” Two sets of family members said the following. “We have been to several service settings and found this the most suitable and we are happy that our X receives the most needed care here.” “The staff inform us when they have problems and if they felt that they are unable to meet certain needs. They keep us informed and we are very happy.” DS0000065605.V349813.R01.S.doc Version 5.2 Page 6 Another relative said, “There is no pressure for us to keep X in the home. Part of the plan is to find out how best to make X independent. This could be X moving into an independent setting. The staff were seen helping people understand and make decisions by using different methods of communications. They used some pictures, objects that the people were familiar with and able to relate to, verbal communication and also recognise the individual body language. The Expert by Experience made the following comments. “All of the residents we met had communication impairments with very little verbal speech. I found out that staff use BSL level 1, picture boards and easy read documents to communicate with residents. I also found out that speech therapists visit the residents at the home.” People who use services are able to make choices about their life style, and they are supported to develop their life skills by the staff. Social, educational, cultural and recreational activities are varied and meet the individual’s expectations. The Expert by Experience made the following statement. “Residents can take part in in-house activities and out-house activities. Activities are co-ordinated by staff and residents can decide if they wish to take part.” We interacted with the five people using the service; we spoke with the staff and checked the care plans including daily progress of the people living at the home. It was evident that the staff were sensitive and flexible when supporting and delivering care. The staff worked towards maintaining privacy, dignity and independence of those living at the home. When we toured the home, the deputy manager knocked on the doors before entering the rooms. The Expert by Experience and the support manager toured the premise with the deputy manager later on in the day. These were their comments. “I found the home was welcoming and very neat and tidy. We first looked in the large living room where one resident was watching TV and another was sitting on the floor. We then looked into the large dinning room where several staff members and residents were sat. All the bedrooms were decorated to each residents taste and they even had their own furniture in the room.” The supplying pharmacist had carried out regular audits of medication management and the staff had complied with the recommendations. Three Medication Administration Sheets were checked against the medication supplied and prescribed. They were satisfactory. The manager and the staff said that staff were following a distance learning course on safe handling of medication. One relative made this comment. “Senior carers have a good understanding about the conditions and they have experience and knowledge about their clients to know when to inform the doctor.” There was a clear complaints procedure, which was accessible to the visitors. DS0000065605.V349813.R01.S.doc Version 5.2 Page 7 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. DS0000065605.V349813.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 DS0000065605.V349813.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): 2, 3 and 4 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The people who wish to use the service and their representatives have the information needed to make an informed decision about the home, based on whether the service is able to meet their needs. Before agreeing admission the needs of the person are assessed and the management of the home and the representatives of the persons agree on the Terms and conditions of the stay. EVIDENCE: Four care plans were checked and staff were interviewed. All the people living at the home had documentation to evidence that they were admitted to the home following a full needs assessment. The assessment process involved the people, their relatives and the care managers. One of the care staff said, “Often the residents were unable to let us know their needs. But their relatives and care managers help us.” Two sets of family members said the following. “We have been to several service settings and found this the most suitable and we are happy that our X receives the most needed care here.” DS0000065605.V349813.R01.S.doc Version 5.2 Page 10 “The staff inform us when they have problems and if they felt that they are unable to meet certain needs. They keep us informed and we are very happy.” The care plans confirmed that the staff delivered the care in accordance with the assessed needs of the individuals. The staff said that trial periods were offered to the young people before agreeing to their permanent stay. This was to find out their suitability to live with the existing people at the home. One relative said, “There is no pressure for us to keep X in the home. Part of the plan is to find out how best to make X independent. This could be X moving into an independent setting.” DS0000065605.V349813.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive at the home. EVIDENCE: Two relatives confirmed that changing needs of their sons/daughters and their personal goals were reflected in their daily care. They also said that care plans were available for them to read and the staff kept them informed of any changes if they were unable to attend care reviews. The staff kept daily records of the care delivered. Staff were seen helping people understand and make decisions by using different methods of communication. They used some pictures, objects that the people were familiar with and able to relate to, verbal communication and also recognise the individual body language. We saw boxes of items, which DS0000065605.V349813.R01.S.doc Version 5.2 Page 12 some people used to communicate with. For example a spoon for dinnertime and a purse for shopping. These are some of the comments by the Expert by Experience “All of the residents we met had communication impairments with very little verbal speech. I found out that staff use BSL level 1, picture boards and easy read documents to communicate with residents. I also found out that speech therapists visit the residents at the home.” The manager was in the process of introducing person centred care plans and working towards staff training and implementing this during the next few months. DS0000065605.V349813.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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use services are able to make choices about their life style, and they are supported to develop their life skills by the staff. Social, educational, cultural and recreational activities are varied and meet the individual’s expectations. EVIDENCE: The people living at Woodview were able to participate in valued and fulfilling activities. It was noted that they were taken out shopping and to see shows so that they have opportunities to interact with people outside the home. The key workers escorted people on outings and gave them support, as they needed. The Expert by Experience made the following statement. DS0000065605.V349813.R01.S.doc Version 5.2 Page 14 “Residents can take part in in-house activities and out-house activities. Activities are co-ordinated by staff and residents can decide if they wish to take part. In-house activities include: • Arts and crafts • Cooking skills • Reading • Music • Swimming • Multi sensory • Take away nights Out-house activities include; • Bowling • Shopping • Theatre • Shows” We found that the young people were given access to a range of activities, which were suitable for their needs. The adjacent swimming pool was fully used by the people living at the home. This has been possible by staff working at the home completing the course on life saving and the safe usage of the hydrotherapy pool. We observed the staff and the people in the pool enjoying the water and exercising in it. On the day of our visit the hydrotherapy manager who is an experienced physiotherapist was supporting the people and the staff. The daily routines were flexible and helped to promote independence. These were some of the comments received. “The people living at the home are unable to open or read mail delivered to them, so the manager or the senior staff read the mail to them. Very rarely they get any mail.” “When we visit we see the staff mixing well with the residents, they chat and joke with them.” The Expert by Experience made the following comments. “Residents go shopping with staff in a group for food and go on a one to one basis for clothes and personal shopping. Residents are able to give an indication of what food they would like to buy. Staff encourage residents to eat healthier by providing a healthy choice of meals with fresh meat and 5 portions of fruit and vegetables everyday. As the residents had very little communication the staff said they listen to parents/carers to find out like and dislikes with food. One staff member said “if they don’t like what has been made we will make something else and try that.” The staff also said that there are no set times for meals and that the kitchen is open 24 hours a day. DS0000065605.V349813.R01.S.doc Version 5.2 Page 15 I also think that the residents should have picture menus to be able to point out what they would like to eat.” The above comments were shared with the manager of the home on the day of the site visit. DS0000065605.V349813.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice by the staff working at the home. EVIDENCE: We interacted with the five people using the service; we spoke with the staff and checked the care plans including daily progress of the people living at the home. It was evident that the staff were sensitive and flexible when supporting and delivering care. The staff worked towards maintaining privacy, dignity and independence of those living at the home. When we toured the home, the deputy manager knocked on the doors before entering the rooms. She also got permission from those who were around as to whether they would like to show their bedroom to us. One person was very happy to take us into his/her bedroom and show the room. Another person through their body language demonstrated to us that s/he was happy for us to look around. DS0000065605.V349813.R01.S.doc Version 5.2 Page 17 This was a comment made by the Expert by Experience, “When looking around the bedrooms I was a bit worried I did not have the permission of residents but I liked the fact residents are able to choose how to have their rooms decorated.” The present manager assured us that she was in the process of making contact with local general practitioners, health professionals and the primary care teams and develop net working. Although there have been some incidents where health professionals had raised concerns about the lack of consultation by the staff at the home with regards to the care of the people using the service this matter has been addressed by the Responsible Individual and the new manager and problems have been resolved. On the day of the site visit it was noted that the supplying pharmacist had carried out regular audits of medication management and the staff had complied with the recommendations. Three Medication Administration Sheets were checked against the medication supplied and prescribed. They were satisfactory. The manager and the staff said that staff were following a distance learning course on safe handling of medication. The following comments were received. “We don’t get to handle medicines until we have completed the course. Only the seniors give out medicines.” “Senior carers have a good understanding about the conditions and they have experience and knowledge about their clients to know when to inform the doctor.” DS0000065605.V349813.R01.S.doc Version 5.2 Page 18 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. People who use the service are able to express their concerns and have access to a complaints procedure. The people are protected from abuse, and have their rights protected by the home’s policies, procedures and staff training. EVIDENCE: There was a clear complaints procedure, which was accessible to the visitors. The following comments were received with regards to this outcome area. “We have not been pleased with the local management for sometime but on the whole we know that A gets the best care. Recent changes have been for the best and we are much satisfied.” “The staff keep us informed of any changes or incidents. We never had to make complaints because of the good communication between the staff and us.” There has not been any record of formal complaints during the last twelve months. All staff have had training on Protection Of Vulnerable Adults. The staff were able to explain what abuse was and how they go about preventing and reporting abusive incidents. DS0000065605.V349813.R01.S.doc Version 5.2 Page 19 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, 27 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The expert by experience and the support manager toured the premise with the deputy manager. These were their comments. “I found the home was welcoming and very neat and tidy. We first looked in the large living room where one resident was watching TV and another was sitting on the floor. We then looked into the large dinning room where several staff members and residents were sat. All the bedrooms were decorated to each resident’s taste and they even had their own furniture in the room. DS0000065605.V349813.R01.S.doc Version 5.2 Page 20 Two bedrooms shared one bathroom between them. I was glad to see there were locks on the bathroom doors to give the residents privacy in the bathroom. We then looked in the sensory room which was very colourful and all lit up. We were then shown to the Hydrotherapy swimming pool, which I found out, was very warm water. The member of staff told me that all staff now have their lifesavers certificates and the pool attendant is also a fully trained physiotherapist. I was concerned that as the pool is hired out by other users this may affect the safety of the residents.” We would like to offer some explanation to the above comments. There was a door between the home and the pool area. This was kept locked by the staff working at the home. Only the staff had access to the key to open the door leading to the pool. Therefore the people living at the home were safe. Access to the home through the swimming pool area was denied to the outside pool users at all times when the pool was opened to the public. DS0000065605.V349813.R01.S.doc Version 5.2 Page 21 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): 31, 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff are trained, skilled and in sufficient numbers to support the people who occupy the home. They contribute to the smooth running of the service. EVIDENCE: Four staff files were checked, five staff were spoken with and three staff surveys were referred to and two relatives comments with regards to this outcome area have been included. The four staff files contained all of the information required to evidence a rigorous recruitment of staff by the management. There had been some confusion about the roles and responsibilities of the deputy manager, the team leader and the manager working at the home. “Y tells us to do one thing and discounts what the manager had told us. There is no respect between local managers.” “There is a lack of leadership and the staff have to pick up the pieces. It is not right.” The Responsible Individual has DS0000065605.V349813.R01.S.doc Version 5.2 Page 22 addressed these areas. The new manager is expected to monitor and manage such situations. The five staff said that they received regular supervision and support, there was a lack of formal supervision records kept by the management. There was a discussion between the manager and us with reference to mandatory training topics and the frequency of training. It was agreed that the home’s policies and procedures needed to reflect the decisions and need to have supporting risk assessments to demonstrate that the staff were competent and skilled to carry out their duties. DS0000065605.V349813.R01.S.doc Version 5.2 Page 23 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, 40 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness, respect and includes the people and their families in the running of the home. The present management promotes a good standard of care and support and follows this by regular monitoring and making improvements based on the findings. EVIDENCE: A new manager has been appointed and it is expected that she would be applying to be registered with the Commission for Social Care Inspection. The Responsible Individual continues to monitor the home each month and provides a report with recommendation to the manager. The manager showed DS0000065605.V349813.R01.S.doc Version 5.2 Page 24 evidence that she responds to the recommendation by putting together an action plan and involving the staff in making improvements. Our site visit took place during the very early days of the new manager appointment. Therefore we have agreed that she needed to have time to settle in before she focuses on the quality assurance of the service. However, the present staff group and the Responsible Individual are committed to providing a good service. Therefore people living at the home receive a good standard of care. DS0000065605.V349813.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 3 3 4 4 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 3 25 3 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 3 36 3 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 X 3 X DS0000065605.V349813.R01.S.doc Version 5.2 Page 26 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. 1. 2. Refer to Standard YA7 YA35 Good Practice Recommendations Information such as activities and list of food menus should be in picture format to help people to understand. The management should ensure that the staff training and development programme and the frequency meet the aims and objective of the home. DS0000065605.V349813.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000065605.V349813.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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