Inspection on 04/07/08 for Lynton Terrace, 1-3

This is the latest available inspection report for this service, carried out on 4th July 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Not yet rated. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lynton Terrace, 1-3 04/12/06

Lynton Terrace, 1-3 23/05/06

Lynton Terrace, 1-3 13/10/05

Lynton Terrace, 1-3 29/04/05

Lynton Terrace, 1-3 20/09/04

Lynton Terrace, 1-3 01/06/04

Lynton Terrace, 1-3 23/06/03

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Lynton Terrace, 1-3 Lynton Road Acton London W3 9DU Lead Inspector Ms Susan Woolnough-Singh Key Unannounced Inspection 4th July 2008 10:40 Lynton Terrace, 1-3 DS0000027756.V364564.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 Lynton Terrace, 1-3 DS0000027756.V364564.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. Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lynton Terrace, 1-3 Address Lynton Road Acton London W3 9DU 0208 992 3343 0208 992 3353 peter.ashworth@hestia.org 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) Hestia Housing & Support Peter John Ashworth Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2007 Brief Description of the Service: 1/3 Lynton Terrace is a detached property, situated in a residential area of Acton and close to Acton Main Line Station and bus routes. Acton town centre is about a mile away and there are local shops nearby. The home is a mental health facility for ten service users, providing medium to long-term accommodation. Hestia Housing and Support manage the home. The communal areas on the ground floor comprise of two lounges, one of which can be used by people who smoke. There is a dining room and kitchen, and a games room. A small kitchenette is located on the first floor. There are ten single bedrooms, four of which are on the ground floor. Three bathrooms, one with a separate shower, are available. All of the bathrooms have toilets and there is one separate toilet close to the communal facilities. The staff sleepingin room, which has its own bathing facilities, is on the first floor. This is also used as the manager’s office. There is a small garden to the rear, with a separate building which houses the laundry room. There is off road and street parking. The staff team consists of a Project Manager, two Deputy Managers, and a team of four Project Workers. They support the service users with personal care, practical tasks and leisure activities. There are no waking night staff and one member of staff sleeps in at night. A new post of housekeeper has been introduced to oversee all of the domestic duties and support service users with practical tasks. The current charges are £742 a week. Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality Rating for this service is two star. This means that people who use the service experience good quality outcomes. This unannounced inspection was carried out on the 4th July 2008. The inspection process took a total of five hours and forty minutes. All of the key National Minimum Standards for younger adults was assessed on this occasion. Nine people were being accommodated at Lynton Terrace. A Registered Manager from another Hestia Service was present during the inspection. A new manager has been appointed since the last inspection, he was on leave at the time of the inspection. The previous manager who was in post during the inspection in April 2007 had left after a short period. We met with two people who live at Lynton Terrance and interviewed two members of staff together. We received ten completed comment cards (surveys) from people who use the service, one comment card from a relative/carer and five staff completed comment cards. Four requirements and four recommendations were made at the last inspection. The timescales for the requirements had been met. What the service does well: What has improved since the last inspection? We noticed areas of improvement since the last inspection in the communal areas of the home, a new cleaning schedule had been put in place. Training for staff has improved and staff have undertaken recent training to assist them in working with people who have mental ill health. Staff spoken with were clear about their role as carer and felt more positive about the aims and direction of the home. Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 6 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. Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The ‘ Guides’ provided to people who use the service contain good information on Lynton Terrace and local services. People have their needs assessed prior to moving in to Lynton Terrace. EVIDENCE: The Statement of Purpose and Service Users Guide had been reviewed and updated in February 2007. The records of three people were examined. These contained a Community Psychiatric Nurse assessment of need. A Licence Agreement was available for each person living at the home. There is a written induction for people new to the service to familiarise them with the home and procedures that are relevant to their residence in the home. Since the last inspection the resident group has remained the same with no new people moving in to Lynton Terrace. Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are available for people who use the service; the plans set out their needs and are reviewed every three months. The presentation of care files could be improved. Staff assist people who use the service to make decisions. People who use the service are able to give their views and suggestions at residents meetings. Risks associated with daily living are assessed as part of the care planning process. Risk assessments will be reviewed if people’s needs change. Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 10 EVIDENCE: The records of three people who use the service were examined. Each file contained a service user care plan, risk assessments and daily records. Care plan headings include personal development, education and occupation, community links, leisure, daily routines and mealtimes. These headings are linked to the Lifestyle Standards (NMS) Care plans contained information on health care and are reviewed every three months. We were able to see that the care plans had been reviewed in 2008. People who use the service have a Key Worker. The risk assessments in place for people covered areas such as protection from financial abuse, self-neglect and health and safety with regard to areas of risk such as smoking. There was recorded evidence that people had met with their key workers for one to one sessions. The care records are kept in large A4 Ring Folders. Some of the information is very dated, for instance old correspondence and assessments. To improve accessibility and clarity of information in is to be recommended that current care plans, risk assessments and review reports be filed separately for every day use and reference. The aims and objectives of the home and needs of people were discussed with the Manager Designate. All require support with daily living although some people are able to experience higher levels of independence than others. Overall, staff need to offer encouragement and support for the people who use the service to carry out the routine tasks of daily living. Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,12,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and staff area aware of the need to assist people in their personal development and engage them in activities and life outside of the home. However, some people who use the service choose not to do this. We have judged that in this area improvements must continue to be implemented for the well being of people living in the home. The comment cards completed indicate that people who use the service and their relatives are satisfied. The provision of meals in the home is good. Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 12 EVIDENCE: We received comment cards from eight people who use the service. People had completed the comment cards and indicated that they have their own routines and are able to make decisions. Additional comments made were ‘I am very happy’ and ‘I would like to move on’. One person wrote that he/she is able to exercise, go out and cook with staff. We met with three people who live in the home and talked with two. People talked in very general terms about life in the home. We received comment cards from two relatives. The response given indicated that they were satisfied with the service. One person commented that his/her relative in the home was not able to make decisions. One person felt that the home had not responded well to complaints/concerns. People who use the service are encouraged to participate in the community and activities outside of the home. However, it appeared from talking to the staff that few people make the choice to do this. People do not have an activity programme. At the time of the inspection people were not attending any supported work, training or educational programmes. The manager designate had been working in the home for approximately a week at the time of the inspection. A shift plan had been produced and was on the wall in the office. The manager said that the purpose of the plan was to encourage staff to assist people living in the home to care for their bedrooms and their home. We agreed with the manager that this is important for encouraging well-being. . It was clear form talking with staff and observation that people need quite a high level of support particularly in the area of motivation to carry out basic daily routines. People who use the service have differing levels of contact with family and friends. Contact will depend on their personal circumstances. Some people are able to visit the family home; others receive visitors to the home. People are offered privacy in their own bedrooms, staff will knock before entering, people have their own front door and bedroom key. There are some restrictions in place around the use of the laundry and kitchen overnight. The Licence Agreement contains the rules on smoking, alcohol and drugs these are also discussed in the residents meeting. Staff cook one meal a day, this is the evening meal. One person is assisted by staff to cook the food of his/her choice. We received a copy of the menu sheet for three weeks. This was judged to be varied and contained Jamaican dishes Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 13 and British dishes. People prepare there own breakfast and lunch with the assistance of staff. A daily record of meals is kept. A housekeeper is employed; she has overall responsibility for the food shopping and will assist people if required. Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff at Lynton Terrace are aware of the level of support and encouragement people need to care for themselves and offer this as required. Staff remind and support people to attend health care appointments with the relevant professionals. It is recommended a form be put in place to record health care appointments and the outcomes of these. The Manager needs to ensure that all people who use the service have a review as required by the Care Plan Approach either every six months or annually. There is a safe system in place for the storage and administration of medication. Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 15 EVIDENCE: People require different levels of support for personal care. Some people are able to maintain a reasonable level of personal care and others require support and encouragement to do this. People who use the service do not require personal care from staff. The care plan contains information on how people will be supported by staff in this area. People have their care reviewed. The information on the files seen did not indicate that reviews were regular. One review had taken place in April, and a request had been made for a review for one person; one fie did not have evidence of a recent review. Action to be followed with regard to the health care of people who use the service is covered in the care plan. At the last inspection we recommended that a separate record of contact with all primary health care professionals such as GP, dentist, optician etc, be instigated to monitor regular appointments. This had not been put in place. On one file a note had been made for one person to see a chiropodist. It was not clear from looking at the recorded information that this appointment had taken place. People are prompted and supported by staff to attend appointments; advice is also given on health issues where needed (such as cutting down on excessive smoking). Information in the Annual Quality Assurance stated t hat some people refuse to self care and choose not to attend appointments. Staff in this situation, continue to monitor and alert health care professionals. The individual risk assessments for people demonstrated that risks relating to mental heath had been assessed. These risks were associated with areas such a self-neglect and behaviour. At the time of the inspection people were not responsible for managing their own medication. Staff administer prescribed medication. A monitored dosage system is used. We looked at the medication administration record and storage cabinet. The Medication administration record was examined and found to be in order. Medication was stored correctly. An Ealing Primary Trust Pharmacist had carried out an audit on the medication system; recommendations had been given with regard to safe storage and administration. Information contained in the Annual Quality Assurance Assessment stated that staff receives training on medication administration, policies and procedures. The Community Pharmacist visits every four moths and carries out an audit. Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures are in place for people to raise their concerns; the evidence seen suggested that these were taken seriously. Staff have policies and procedures to guide them in the protection of vulnerable adults. EVIDENCE: Hestia has a complaints procedure, which is available for people who use the service at Lynton Terrace. There is also a comprehensive list of contacts for support, counselling and social services in the resident’s handbook. People have the complaints procedure explained to them when they move to Lynton Terrace. We looked at the complaints record book. Three complaints had been made. We were able to see that these had been investigated and managed in a satisfactory manner. Hestia has policies and procedures for safeguarding adults. A Whistle Blowing Policy is in place and a policy on the management of service users valuables, money and financial affairs. The Team Development Plan for 2008 indicated that training is planned for Safeguarding Adults. The Manager confirmed after the inspection visit, that this training had taken place in July 2008. One member of staff attended the training at Hestia Head Office and carried out a presentation to the staff team. Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 17 At the time of the inspection one investigation was in process. The details of this were discussed with the Manager at the time of the inspection. We also made a follow up call after the visit to the home. The investigation was near completion. Lynton Terrace, 1-3 DS0000027756.V364564.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, 25,26, and 30. Quality in this outcome area is. This judgement has been made using available evidence including a visit to this service. The accommodation provided for people is satisfactory. The staff team are aware that some improvements must be made for the benefit of people who use the service. Bedrooms for people should be refurbished and updated. EVIDENCE: A tour of the building took place with the Manager. Some improvements had been made since the last inspection and additional improvements planned. There are two lounges on the ground floor. The non-smoking lounge is pleasantly furnished and decorated. The Manager said that there were plans to improve the smoking lounge. The smoking lounge does not have curtains and the seating requires replacing. The paintwork in this lounge has been cleaned since the last inspection. The kitchen and laundry were seen these were observed to be clean and functional. Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 19 We looked at two bedrooms; these were individual and kept to the specifications of the person using the service. The Manager said that staff were being encouraged to offer support to people in caring for their bedrooms. We observed that curtains were closed in bedrooms and bedrooms and judged that bedrooms could look smarter and more comfortable. Some people who use the service spend a significant amount of time in their bedroom. A full time housekeeper is employed and a maintenance person/gardener is also employed. The home was being kept to a high level of cleanliness. Recent work had been carried out in the garden; this looked well-maintained flowerpots had just been planted. Lynton Terrace, 1-3 DS0000027756.V364564.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 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A minimum number of staff are on duty during waking hours to meet the needs of people who use the service. Staff have received training to work with the people who live in the home, and further training is planned. For monitoring purposes the record of staff names and training dates needs to be improved. Recruitment procedures are in place. Recruitment records could not be verified as these are kept at the head office. The frequency of staff supervision needs to be monitored and improved. EVIDENCE: Seven care staff are employed at Lynton Terrance including the manger of the home. There is a good gender balance of male and female staff. The home has staff and people who use the service from various ethnic backgrounds. Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 21 A staff rota for the period 30th June - 6th July was examined. In the morning two care staff including the manager is on duty two people are on the afternoon/evening shift. One member of staff is on duty and sleeps in overnight. Hestia have a recruitment policy in place that takes into account equal opportunities and the protection of vulnerable adults. We looked the files of two members of staff, one of whom had joined the team recently. Staff records seen comprised of training, supervision and appraisal information. We were unable to view staff recruitment records and identity verification as these are kept at the Hestia Head Office. We spoke with the Manager with regard to this and asked that some form of verification be put in place particularly with regard to Criminal Records Bureau Checks. For instance the date when the CRB check is received and a reference number. A staff pro - forma must be in place as a record of when all the necessary recruitment checks have taken place. We were provided with a Team Development Plan. This set out the training plan from June 2008 to March 2009. The plan included mandatory health and safety courses, training on team working, safeguarding adults and mental health. There were timescales on the training plan for identified training to be achieved. We did not see a record of training that had taken place and been completed for all members of staff. Information provided on the Annual Quality Assurance Assessment stated that all staff had attended food hygiene training. Four staff had achieved NVQ Level 2 or above and two staff were in the process of working towards this. We spoke with two members of staff both of who had completed the NVQ Level 2 in care. The members of staff said that changes had been made and there was a new emphasis on ensuring people are supported to care for their environment, and that staff had also been undertaking cleaning work. A shift plan is in place and staff work to a daily schedule. Staff said that they had recently completed training in motivational work. This comprised of techniques in managing interactions with people who use the service and enabling them to work towards their own solutions. Five staff returned surveys. The response given by staff in the survey was positive; staff felt that they had the training and support to carry out their tasks. Staff commented that they supported people and aimed to empower them. On examining one staff file the last record of one to one supervision was found to be in June 2007. Another member of staff had received one to one supervision in April 2008. Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 22 Lynton Terrace, 1-3 DS0000027756.V364564.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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manger Designate was able to demonstrate that plans had been made to develop Lynton Terrace. A clear quality assurance and team plan was in place. However, we judged that the team needs a permanent manager to build the team and improve the service. An action plan is in place to develop the home. Health and safety procedures are in place for the protection of people who use the service Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 24 EVIDENCE: At the time of the inspection we met an experienced Registered Manager from another Hestia Care Home. She had a clear vision of the work she wished staff to carry out to improve the home. Initially, this is to be organising a daily schedule, which includes improved record keeping and housekeeping. Increasing the morale of staff and people who use the service was one of the Manager Designates aims. At the time of the last key inspection in April 2007 a new manager had just commenced and was in the process of applying for registration. He had subsequently left the service and a new manager appointed. The new manager was not available at the time of this inspection. The manager designate was in place. To ensure that the written aims and objectives of the home are being met there must be consistency and stability of leadership. The Annual Quality Assurance Assessment provided by the home was of a very good standard with comprehensive information on how the National Minimum Standards are being met and identified areas for improvement. We received a copy of the Lynton Terrace Team Plan for 2008/09. This covered ten main aims incorporating increased inclusion, advocacy and participation for people who use the service, staff development and more efficient household maintenance. The Team Training and Development Plan indicated that training in health and safety, food hygiene fire safety and first aid had been identified and planned. We looked at fire safety and service records. Fire drills with people who use the service and staff had taken place in January and April 2008. Electrical appliances had been safety tested in June 2007. There was a record of a Legionella test in February 2008 and a Gas Safety Service in June 2008. Hot water checks had last taken place in April 2008. The Annual Quality Assurance Assessment Dataset confirmed that all the required health and safety policies and procedures are available. Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 3 32 2 33 x 34 2 35 x 36 2 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 3 12 2 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 2 x 3 x x 3 x Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA12 YA14 Regulation 16 (2) (m) Requirement The Registered Manager and Registered Provider must ensure that where practicable people who use the service are encouraged and supported to participate in daily activities. The Registered Manager and Registered Provider must ensure that all people who use the service are reviewed as required. The Registered Manager and Registered Provider must ensure that décor, fixtures and fittings in bedrooms are of an acceptable standard, The Registered Manager and Registered Provider must ensure that the record staff training be updated and improved. The Registered Provider must ensure that a record of recruitment and identity verification is kept in the home. The Registered Manager and Registered Provider must ensure that staff are offered one to one supervision sis times a year and this is recorded. Timescale for action 01/10/08 2. YA18 12. (1) (a) (b) 01/09/08 3. YA26 23 (2) (f) 01/01/09 4. YA32 18 (1) (a) 01/09/08 5. YA34 19 (1) (a) (b) 01/10/08 6. YA36 18 (2) 01/09/08 Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 YA19 YA25 Good Practice Recommendations The care files should be reviewed and reorganised to improve access of important information. A format for recording all health care appointments for people who use the service should be developed. Consideration should be given to improving the ambiance of service users bedrooms. Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Lynton Terrace, 1-3 DS0000027756.V364564.R01.S.doc Version 5.2 Page 29 - 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. 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