Inspection on 06/11/06 for 104 Wimborne Road

This inspection was carried out on 6th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

104 Wimborne Road 09/08/07

104 Wimborne Road 22/02/06

104 Wimborne Road 14/09/05

104 Wimborne Road 10/02/05

104 Wimborne Road 29/07/04

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Wimborne Road (104) 104 Wimborne Road Southend On Sea Essex SS2 4JR Lead Inspector Mr Trevor Davey Unannounced Inspection 6th November 2006 10:00 Wimborne Road (104) DS0000015488.V318954.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 Wimborne Road (104) DS0000015488.V318954.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. Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wimborne Road (104) Address 104 Wimborne Road Southend On Sea Essex SS2 4JR 01702 603698 01702 603698 wimbourne@mcch.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) MCCH Society Limited Mr Michael George Sharp Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th. May 2006 Brief Description of the Service: 104 Wimborne Road provides accommodation and personal care for up to six adults with a mental disorder. This includes residents aged 18 to 65 years although some are now over 65 years of age. The registration category does not include people who may have dementia or a learning disability. The premises are a two-storey house in a residential area situated in Southchurch, Southend-on-Sea and is in close proximity to all local community facilities, amenities and transport links. The accommodation includes six single bedrooms all of which have call bells, television and telephone points. There are separate lounge and dining areas, kitchen, and a small garden with a patio. The surrounding area provides good parking facilities. The current rate of fees are £1058 per week (which includes a sum for rent of between £46 and £107.43), plus £29.40 for housekeeping. Additional charges are made for hairdressing, chiropody, transport, toiletries, leisure activities and holidays. Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection site visit took place over a period of 6.25 hours. The visit mainly focused on the progress the home had made since the last Random Inspection and covered all Key standards. The Register Manager was on annual leave and the senior support worker on duty and other staff, all assisted in the inspection. Staff, and residents were spoken with during the site visit. Their comments and contributions received were helpful in assisting the Inspector to compile this report. In addition, Case tracking took place using some of the personal care records and other official records within the home were also assessed. Responses from a survey which had been conducted with residents by the home were also taken into account. The feedback which had been received was complimentary and positive regarding the standard of care and support provided. Where issues had been raised, these had been responded to appropriately with a view to meeting the needs and reassuring residents as well as improving the service provided. The inspection also took into account previous information submitted by the Registered Manager including the completed pre-inspection questionnaire. What the service does well: From conversations with residents, staff, observation during the site visit and feedback from surveys which were available, the home provides a Person centred approach in supporting residents to pursue individual interests and aspirations to meet their preferred lifestyles. There was evidence to show that the staff team regularly interact and engage with residents to support them in pursuing individual interests and leisure activities of their choice. The home is good at discussing care plans and risk assessments with residents and these records are clearly documented and regularly reviewed. There was evidence to show that there were several examples where residents were now pursuing a more fulfilled lifestyle as well as being enabled to live more independently so far as this was possible. Survey information Tell us what you think, was in the process of being collated. Residents had been advised that the survey returns would be used as a means of helping staff to maintain and where necessary, improve the quality of service offered at the home. Meetings are regularly held with residents and copies of minutes were available in the lounge. Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 6 Some of the residents spoken to, stated they enjoyed the opportunity of meeting residents from other homes for social occasions as well as being able to be involved in leisure and occupational activity in the local community. The staff team work well together and have a good rapport with residents. Regular supervision and training is provided and courses regularly take place to update staff on essential practices and procedures. The accommodation and facilities provided in the home are ideally suited to meet the needs of residents. What has improved since the last inspection? What they could do better: The Inspector acknowledges the ongoing efforts of the Manager and Service Co-ordinator to improve communication and working arrangements with the mental health care team of the Primary Care Trust. Whilst there have been some positive examples of good practice and imput from the community health care team, copies of correspondence sent to the Commission for Social Care Inspection, still identify issues where there has been a lack of response and uncertainty with regard to support and back up arrangements which can be expected to ensure residents receive proper provision of care and support. Although responsibility for checking staff recruitment records is handled by the Register Provider from their central office, a list was available in the home of references and criminal records bureau checks which had been completed. This showed that one C.R.B. check had not been completed although it is understood that the member of staff concerned is working in the home on occasions. Staff should not be left alone with residents and must be supervised at all times until the full recruitment checks have been completed. Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 7 There was no record that monthly visits have taken place to the home by the Responsible Individual or their representative, since July 2006 in order to monitor the service or the standard of care provided, in accordance with Regulation 26 of the Care Homes Regulations. 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. Wimborne Road (104) DS0000015488.V318954.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 Wimborne Road (104) DS0000015488.V318954.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 Quality in this outcome area is good. Admissions are not made to the home until a full needs assessment has been undertaken reflecting individual aspirations. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The admission and placement of residents in and out of the home is very infrequent and several have been resident for a number of years. Some of the original pre-admission assessment information had been archived but details of more recent admissions were available. This included brief family and nursing history which was included in correspondence and gave an overview of diagnosed health conditions as well as hospital stays. Reference had also been made as to progress made at a rehabilitation unit. A full mental health assessment had been completed by one of the members of staff which had comprehensive details and relevant information relating to current situations and reason for referral. The assessment also included details of activities attended which involved art and occupational therapy as well as community involvement. Information regarding personal history, family contacts as well as sensory problems, both past and present, had also been documented. Assessment information also included information relating to the phasing in period of three months at Wimborne Road prior to permanent admission. Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 10 Profiles had been prepared giving an overview of communication, relationships staff and social/domestic activities. All prospective admissions include short stay visits with overnight stays to determine suitability of the placement and to ensure the home is able to properly meet residents needs. Following admission, care plans together with risk assessments had been compiled to reflect individual goals and aims as agreed with residents. Whilst all the existing residents appear to be suitably placed and their needs are being met, it was noted that one of the residents had been admitted to the home although they were over 65 years of age at the time. If it is the intention of the Registered Provider to admit residents who are over 65 years of age in the future, then it will be necessary for an application to be submitted to the C.S.C.I. for a variation in the registration to admit older people with mental health problems. Copies of the latest Statement of Purpose and Service Users Guide which had been updated earlier this year, were also available in the hallway together with the latest inspection reports issued by the Commission for Social Care Inspection. Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is excellent. Care plans together with risk assessments, were in place which had been drawn up following discussion with residents, taking account of individual needs and showing how support is to be provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Case tracking took place in respect of two residents as well as inspecting other personal care records. Where possible, conversations also took place with residents who were willing to talk to the Inspector. Care plans were Person centred, clearly documented, easy to follow and regularly evaluated. Comments from residents confirmed that staff were supportive and discuss care needs on an individual basis. Care plans had been signed by residents as well as members of the staff team. The layout was Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 12 clear which included the date, identified need, objective, expected outcome and review date. Daily and monthly valuations had also been recorded. This included information where residents had attended in-house reviews. Examples of care plans prepared covered social activities, budgeting skills, washing, drying, laundering and use of equipment. Risk assessments had also been prepared and updated which were clearly indexed. Individual personal files for residents included a number of sections covering assessment details, health and safety, reviews and goals. Residents have the opportunity of enjoying an improved quality of life and are encouraged to be as independent as possible with the added support of staff where required. Residents are able to go out into the local community on their own to pursue leisure activities including shopping, visiting pubs and the Rethink centre. Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is excellent. The home provides support to residents in pursuing social and recreational activities in accordance with individual needs and choices which is linked into the local community. Where possible, residents are able to enjoy regular appropriate family and personal relationships. Residence rights are respected and daily responsibilities in the home encouraged. This judgement has been made using available evidence including a visit to the service. EVIDENCE: From discussion, observation and records available, there is evidence to show that residents are encouraged to enjoy and take part in leisure and recreational activities within the local community. Residents are welcomed and accepted by local shopkeepers/traders all of which, are easily accessible and Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 14 near to the home. Visits to local pubs and restaurants have also taken place as well as to art classes including ceramics and music appreciation sessions. Some residents are able to travel independently by public transport. Staff have also accompanied residents to football matches, the theatre and social occasions have been arranged giving residents opportunity to meet with residents from other homes in the area. Records of activities attended by residents and involvement in the home itself, were available including daily and nightly log reports. Responses to the survey questionnaires completed by residents made reference to the new opportunities they had to go out into the community and make new friends. Where matters of concern or uncertainty had been raised, the manager had written personally to residents concerned with suggestions as to how issues could be improved or resolved as well as giving opportunity for these to be explained in more detail by staff if necessary. Some of the care plans had identified needs such as providing more motivation for residents to be involved with the local community and to expand interests. Residents are encouraged to be involved in communal house tasks involving cleaning and vacuuming and each person has an opportunity of preparing and cooking meals on a rota basis. Menus are discussed and arranged by the residents themselves with the support of staff. Records of meals chosen and provided to residents were available as well as alternative meals where these had been requested. There was a whiteboard in the hallway showing the name of the member of staff on duty and night cover, the dinner being provided for the day and the resident involved in preparing the meal as well as the day’s weather forecast. From conversation, observation and the inspection of records, there was evidence to show that the core values of rights, privacy, choice and independence were being upheld. Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is adequate. Assessed and identified care/health and emotional needs were being met appropriately but communication and positive support from other health care professionals was not always consistent. Policies and practices on medication were being followed for the protection and well-being of residents. This judgement has been made using available evidence including a visit to the service. EVIDENCE: As already referred to in this report, the staff team are good at providing personal and group interaction with residents taking into account individual needs and preferences. Care plans and other personal records together with comments from residents, were able to evidence a good rapport within the home between residents and the staff team. Where difficult situations have arisen with cases of aggression and other behavioural issues, staff have managed situations well and have introduced appropriate risk assessments. Other imput has been received from health care professionals but as referred to in the previous two inspection reports, there continues to be instances Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 16 where communication and support from the mental health care team of the Primary Care Trust has not been consistent. Copies of correspondence which have been sent to the mental health care team have been sent to the Commission for Social Care Inspection. These identify concerns the home had regarding regular outpatient appointments, lack of response relating to the attendance of reviews in the home and cases where community psychiatric nurses have not been available for individual residents. In one case, although correspondence had taken place over a four-month period as well as telephone calls, no response had been received. The management of the home has attempted to establish an agreed framework whereby the home can work in partnership with the mental health care team to ensure that health and emotional needs of residents are being met. At the time of this inspection, the Inspector was advised that three of the residents had not been allocated a community psychiatric nurse. Where it has been necessary to contact the Crisis Intervention Team, there have been occasions where telephone numbers had been changed without the home being advised which could place the staff team in difficulty when dealing with emergency situations. In other cases, the home has been advised that where there are behavioural issues, this should not be an issue where the Crisis Intervention Team should be involved. As part of the policy for placing people with mental health problems into the community, there should be appropriate professional input from community psychiatric nurses and consultants to ensure staff are properly supported to meet the needs of residents in their care. The Senior Co-ordinator and other senior managers representing the Registered Provider, are aware of these issues and meetings have taken place with the mental health care team with a view to improving communication and the service provided to residents. A clear understanding as to the working arrangements and support which the home can expect to receive, must be agreed together with achieving effective communication procedures with health care professionals. This is important in the interest of residents and for properly monitoring their ongoing mental health needs. As this issue is still not fully resolved, the Registered Provider should make urgent contact with the Primary Care Trust with a view to discussing a positive way forward for overcoming the current difficulties. It is recommended that contact should also be made with the Mental Health Commissions who have quarterly meetings with the Registered Provider regarding these issues. A sample check was made of the medication administration records and entries had been completed in accordance with agreed procedures. Protocols had been completed for P.R.N. (to be taken as required) medication and records of drugs which had been received and returned to the pharmacist were also available. Staff who are responsible for administering medication had all been trained and evidence of courses completed and assessments, were made available to the Inspector. Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is Good. There is an established complaints procedure in place and residents views are listened to and acted upon. Staff have an understanding of the reporting procedure for the prevention of harm to vulnerable adults, ensuring that the safety of residents in the home is of paramount importance. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure which is included in the Service User Guide. The home was able to demonstrate that its procedures are effective in dealing with any concerns or issues which residents may raise. Meetings are arranged with residents normally every month and copies of these minutes were available in the lounge together with the attendance sheet. The survey questionnaire completed by residents also indicated that they were aware of the complaints procedure and how the process worked. Residents are also made aware of the advocacy service should this be required. All staff have attended training regarding prevention of harm to vulnerable adults and details regarding the reporting and whistle blowing procedure and the agencies to be contacted, were available in the office. The home has been able to demonstrate that where such issues arise, prompt and appropriate action has been taken in order to ensure the safety of residents in the home. Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is Good. The home provides a physical and safe environment that is appropriate to the specific needs of residents who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection, improvements had been made including the installation of a new hot water boiler which has improved the effectiveness and distribution of central heating in the premises. The accommodation and facilities are comfortable and meet the needs of residents. Residents are encouraged to be involved in cleaning and domestic chores on a rota basis. Lockable accommodation had been provided for the safe storage of cleaning materials and regulations referring to the control of substances hazardous to health were in place. Cleaning schedules had been Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 19 drawn up covering daily, weekly and monthly tasks. It is recommended that as part of the normal training programme, arrangements are made for staff to attend a course on infection control and for these measures to be taken into account as part of the normal routine to minimise the outbreak of infection in the home. Wimborne Road (104) DS0000015488.V318954.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): 32,33,34 & 35. Quality in this outcome area is Good. The number of staff on duty, with support and supervision, was able to meet the needs of residents who have confidence in the care provided. Residents are protected by the homes recruitment procedures. Overall, the training programme equips the staff appropriately to meet the needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A rota was available which recorded the named staff on duty. At the time of inspection, two staff were available for each of the early and late shifts and at night, one member of staff was on awake duty and another rostered for ‘sleeping in’, to be available if required. When the manager is on duty, there is provision for three members of staff for the morning and afternoon periods. At the time of this inspection, there were two full time and part- time vacancies respectively. Cover was being provided by existing staff as well as bank staff from other homes in the area. Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 21 Staff recruitment files were locked away as the manager was on leave. However, a list of staff where references had been obtained together with criminal records bureau checks, was made available. It was noted that one member of staff had been rostered to work in the home although clearance of the CRB check was still awaited. The staff were reminded by the Inspector that no staff should work on their own and without being supervised until all recruitment checks had been completed. An arrangement has been agreed with the Registered provider for the Provider Relationship Manager of the Commission for Social Care Inspection to check recruitment records twice a year at the Central office in Maidstone. Should there be any shortfalls or concerns, these will be addressed at the time and the Inspector notified accordingly. The record of training courses completed by staff was made available for inspection. It is understood that although a request has been submitted, staff are still awaiting to attend training related to strategies for crisis intervention and prevention (SCIP). As there have been previous in incidents where residents have been verbally and physically aggressive towards staff, there is a need for these arrangements to be finalised in order that staff can be fully equipped to deal competently with issues relating to managing aggressive behaviour. Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is Good. The Registered Manager has considerable experience which has been positively utilised in the daily operation of the home to meet its stated purpose, aims and objectives. Systems are in place to ensure that the needs and views of residents are taken into account for improving the service. The standards for health, safety and welfare of residents and staff are maintained. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The Manager is experienced and has demonstrated managerial skills in the daily operation of the home in the interests of residents as well as promoting the skills of the staff team. Key staff have delegated responsibilities and Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 23 effective communication/training takes place to assist in the smooth running of the home. As already referred to in this report, the views of residents are sought on a regular basis both in regular meetings, one-to-one conversations and the completion of survey questionnaires. At the time of the inspection, a copy of any report in respect of any review of the home or development plan was not available. Once available, a copy of this report must be sent to the Commission for Social Care Inspection as well as feedback given to residents in a format that can be understood, should this be required. The last monthly monitoring visit (under Regulation 26 of the Care Homes Regulations), by the Responsible Individual or their representative took place in July 2006. No record of visits made since that date was available. The pre-inspection questionnaire had details of regular servicing which had been carried out in respect of health and safety, including fire equipment checks, health and safety department, electrical wiring and gas safety checks. In addition, fire warden training was completed by two staff and dates of fire drills carried out in the home were available. Safe environment work risk assessments were in place and these are reviewed on an annual basis and updated as required. Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 4 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 x 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 x 2 x x 3 x Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 25 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 YA19 Regulation 12 & 13 Requirement The Registered Person must continue to ensure that clear & reliable arrangements are in place with the Primary Care Trust to ensure proper provision for the care and where appropriate, treatment and supervision of service uses is provided and that any necessary advice and other services from the mental health care team are available. (previous timescales of 31/03/06 & 31/07/06 not met). Timescale for action 31/01/07 2. YA34 19 (Sched.2) 3. YA35 18 The Registered Person shall not 15/12/06 employ a person to work at the care home unless all recruitment checks have been completed, including Criminal Record Bureau checks. The Registered Provider, having 31/01/07 regard to the size of the care home, the number and needs of residents, ensure that the persons employed receive training appropriate to the work they are to perform. This refers to suitable training being provided to enable staff to be DS0000015488.V318954.R01.S.doc Version 5.2 Page 26 Wimborne Road (104) 4. YA39 24 competent in managing aggressive behaviour. The Registered Person shall provide a copy of any report /development plan following a review of the care home, to the Commission for Social Care Inspection and a copy made available to service users. (previous timescale of 01/10/06 not met). The Registered Person must visit the care home to inspect the premises and consult with residents regarding the care provided as part of a monitoring visit, and supply a monthly written copy of the report to the Commission for Social care Inspection. 01/02/07 5. YA39 26 31/12/06 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 YA30 YA19 Good Practice Recommendations It is recommended that staff are provided with training related to infection control measures that can be used in the home. It is recommended that the Registered Provider arranges to consult the Primary Care Trust at senior level, with a view to establishing clear and agreed procedures for professional support, in order to appropriately address the mental health needs of residents. Wimborne Road (104) DS0000015488.V318954.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Wimborne Road (104) DS0000015488.V318954.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. 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