Inspection on 31/05/07 for 11 Allenby Road

This inspection was carried out on 31st May 2007.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

11 Allenby Road 12/09/05

11 Allenby Road 21/04/05

11 Allenby Road 26/10/04

11 Allenby Road 08/06/04

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

CARE HOME ADULTS 18-65 11 Allenby Road Maidenhead Berkshire SL6 9BF Lead Inspector Kerry Kingston Unannounced Inspection 31st May 10:30 11 Allenby Road DS0000046683.V330911.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 11 Allenby Road DS0000046683.V330911.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. 11 Allenby Road DS0000046683.V330911.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 11 Allenby Road Address Maidenhead Berkshire SL6 9BF 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) 01628 783573 s.humphrey@owl-housing.org Owl Housing Limited Mrs Barbara Susan Humphrey Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 11 Allenby Road DS0000046683.V330911.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 2005 Brief Description of the Service: The service is operated by Owl Housing Limited, and is registered to provide accommodation and care for six service users between the ages of eighteen and sixty-five, who have a learning disability. Most of the service users also have associated physical disabilities. The accommodation is provided in a purpose-built, single storey unit in a residential area of Maidenhead. There is disabled access to all areas of the building and each service user has their own bedroom. The property has a small landscaped garden, with a level patio area and some raised beds. It is within easy reach of local transport links, shops and leisure facilities and has its’ own transport. The fees are £1, 264 per week for all of the people who use the service. 11 Allenby Road DS0000046683.V330911.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report for the key inspection which included a routine unannounced site visit. This took place between the hours of 10.30am and 7.00pm on the 31st of May 2007. The information was collected from a pre-inspection questionnaire and Annual Quality Assurance Assessment, completed by the manager, surveys were sent to people who use the service, other professionals and families of residents, six were received in response. Discussions with two staff members, the deputy manager, the registered manager and two people who use the service took place. There was further communication with and observation of other people and staff during the course of the visit. Two people who use the service are able to communicate verbally but the other four communicate by various methods and some are not responsive to people they are not familiar with. A tour of the home and reviewing service user and other records was also used to collect information on the day of the visit. What the service does well: What has improved since the last inspection? The people who live in the home go to a ‘weekly tenants’ meeting so that they know what is going on and can say what they think about living there. 11 Allenby Road DS0000046683.V330911.R01.S.doc Version 5.2 Page 6 The staff now have proper written references, before starting work so that the manager knows what they were like at their last job and can decide if they would be able to be part of the staff team. The home has quite a lot of ways to check that they are giving proper care to the residents and tries to make things better for them. 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. 11 Allenby Road DS0000046683.V330911.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 11 Allenby Road DS0000046683.V330911.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): 2. People who use the service experience good quality outcomes in this area. The home makes sure that people who are to be admitted are properly assessed, the home can meet their needs and that they are involved in choosing whether they wish to live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One person was admitted on the 7th May 2007, she had a full assessment by a care manager before admission and was fully involved in the application and admission process. Three planning meetings were held, all issues affecting the individual were discussed and an introductory programme was initiated. Assessments also included a physiotherapy assessment and the resident ‘trying out’ her room to ensure it met her particular needs, before admission. The ‘Essential Lifestyle Plan’ (detailed care plan) was not completed prior to admission and the staff team work on a set of ‘guidelines’ until the full care plan document is completed. The Annual Quality Assurance Assessment notes for improvement, that the Care Plan should be completed prior to admission. The admission is to be reviewed three months after admission but the date has not been set yet. 11 Allenby Road DS0000046683.V330911.R01.S.doc Version 5.2 Page 9 The resident said ‘it’s a nice place to live’ ‘I chose to live here’. She is able to communicate clearly and can tell staff her likes/dislikes and make her preferences known. The Statement of Purpose and Service User Guide have been reviewed and are up-to-date but the newly resident person does not have an individualised contract/statement of terms and conditions yet, it was discussed that this is another document that should be in place prior to admission or shortly after. 11 Allenby Road DS0000046683.V330911.R01.S.doc Version 5.2 Page 10 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. People who use the service experience good quality outcomes in this area. The home makes sure that people are as involved in the care planning process as possible and that they are able to make as many decisions for themselves as they are able. The staff team tries to maintain and enhance peoples’ independence skills wherever appropriate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were seen (called Essential Lifestyle Plans), two were for people who had been living in the home for eleven years. They are detailed and include relationships, day services, food and drink, possessions, essential knowledge, Health and Safety, routines and support for challenging behaviours. They are reviewed six monthly, one review is led by the care management team and one by the home. Notes from the review are produced 11 Allenby Road DS0000046683.V330911.R01.S.doc Version 5.2 Page 11 in pictures and photographs and include ‘what I would like to plan for next year’ to describe the individuals aims and goals. The pictorial format was introduced by the home in 2006. A needs assessments in residents’ files also includes communication, independent living, intimate care, physical contact, dignity /respect, how to give choice, being at home and relationships. Equality and diversity issues, particularly around physical and sensory difficulties are addressed by the individual care plans. A weekly tenants meeting is held, introduced in 2006, they have limited content to ensure people are able to understand what it is about. At the meeting people can contribute to the menu formulation, discuss activities and other day-to-day issues. Care plans have ‘how to give choice’ as a heading, for staff guidance. People were observed choosing clothing and activities for the day. One person chose to go shopping with staff rather than attend a weekly group. She told me how she had chosen to buy a new top and that she had been helped to choose the colour by her key worker. What people think of the care they receive and if its’ still meeting their needs, is discussed at reviews, residents attend if they wish. One person confirmed that she can make choices and do as she wishes, she was seen to choose to have an overnight visit (on the day of inspection) and transport was provided. Risk assessments are in place and cover all necessary areas. They include independent living and domestic tasks that people can help with. Risk assessments for holidays and community activities are produced, including providing 2:1 staffing to enable people to go on holidays and access the community. Staff were observed discussing risk assessments and safety of people prior to a shopping trip, they devised a plan that enabled them to take two people (instead of one) to participate and complete the task safely. 11 Allenby Road DS0000046683.V330911.R01.S.doc Version 5.2 Page 12 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. People who use the service experience good quality outcomes in this area. The home helps people to enjoy their lifestyle by offering interesting and varied activities, supporting people to access the community and providing good quality food. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three activities programmes were seen, people attend between two and four sessions, participating in external activities each week. The programmes are designed to suit the individuals’ preferences and needs and include attending the local day centre and attending college. On the day of the inspection visit the local day centre was closed and people were participating in activities with staff. Activities, which are not planned in advance, are not always recorded in detail in daily diaries and it is difficult to see all the activities that occur. On the evening before the inspection visit a 11 Allenby Road DS0000046683.V330911.R01.S.doc Version 5.2 Page 13 birthday bar-b-que had taken place and the residents indicated or said that they had enjoyed it. Two people said that they ‘have plenty to do, they ‘never get bored’. One person described her party and the other described her shopping trips. There was also evidence of trips to the community for haircuts, shopping for the home, lunches out, monthly church visits, attendance at the social club once a week and annual holidays. People have limited involvement in meal preparations and kitchen activities, as the kitchen is too small, the Annual Quality Assurance Assessment outlines plans to address this problem. An advocate survey said ‘has an active social life, attends courses and church’. A professional survey said ‘indoor activities are limited by the kitchen’ Two of the six people who live in the home have close family contact and one has an advocate. A survey received from two family members said that they are ‘always or usually kept in touch with what’s going on’. One person said she had a party where her friends and family were invited. One care plan noted a long- term aim as ‘encouraging them to have friends round and communicate with them, rather than staff.’ Contact with family and friends is noted in Care plans and relationships is noted as an area of care. Peoples’ rights and responsibilities are detailed in the Service User Guide and staff were able to describe how they discuss and explain their rights and responsibilities within the home to the people who live there. They were also able to detail how they ensure privacy, dignity and respect. A professional survey noted too many staff in a bedroom where she was working with an individual, this issue was noted as being discussed at a staff meeting, written guidelines are now in place for if staff have to support a person with a health consultation. Menus seen are well balanced and healthy, dietician advice is sought as necessary. One person is underweight and tends not to eat, one person is over weight. Supplements are given to one and a weight reducing/healthy eating plan programme is in place for the other. Two people said ‘the food is good, we have some good cooks here’. One person confirmed that she could choose other things if she did not like what was on the menu. People are given appropriate help at mealtimes and the dining room is comfortable and pleasant. 11 Allenby Road DS0000046683.V330911.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. People who use the service experience good quality outcomes in this area. The home supports people to look after personal care needs by having detailed care plans which include peoples’ preferences. The home ensures people have good access to health professionals, as necessary and medication is safely administered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans seen describe peoples’ likes/dislikes and preferences, how staff give intimate care and how to ensure that the individual maintains their dignity, respect and choice. The home has a same gender care policy, although female staff can help male residents with personal care, male staff do not assist female residents. Written routines note how and when people like to be supported with their personal care. A professionals survey noted ‘no concerns about the care’, ‘care is provided to a high standard’, a family survey said ‘care of residents is exemplary’. One 11 Allenby Road DS0000046683.V330911.R01.S.doc Version 5.2 Page 15 person said that she enjoyed ‘her shower this morning’, it appeared to be a pleasurable experience for her. People were well dressed, their clothing reflecting their own choices and personality and personal hygiene was good. Behavioural guidelines are developed for those who need support in this area, physical restraint training is given to staff but physical interventions are not used in the home. There is a detailed Policy with regard to physical contact between staff and residents. Medical records are detailed and accurate, one person’s records showed regular check ups by the optician, the dentist, a flu jab and psychologist and epilepsy specialist appointments. Appointments and the results of them, with any necessary follow- ups are clearly recorded. Seizure charts, weight charts and behavioural charts are also kept, as necessary. A health professional said ‘satisfied with overall care, one family survey said ‘physical and emotional needs are so well cared for’. Records were seen of the manager supporting a resident to get the best possible care from the hospital and the support the staff team had given him during his admission. Two medication errors were noted in an eighteen-month period, appropriate action was taken and the procedure amended to minimise the possibility of a repeat of the errors. Two staff always administer and sign the medication records. The instructions for the administration of medication are clearly displayed in the medication cabinet. Individuals’ medication files have instructions how to administer their medication in the most effective way and the way they prefer. There are also guidelines noting what to do if they refuse to take necessary medication. The process used to give medication was observed and adhered to the written procedures and individuals’ guidelines. The Boots Monitored Dosage System is used to administer medication. Medication records seen were accurate. Guidelines for the administration of ‘as necessary’ medication, particularly medication to assist with behavioural control could be more detailed, this was discussed with the manager. Staff are trained in medication administration and their competence is assessed by a manager from another home. Staff also receive training in any other conditions that people in the home may need help with, such as epilepsy. Staff confirmed that they received medication and health training and these courses were also outlined on the training programme for the home. 11 Allenby Road DS0000046683.V330911.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. People who use the service experience good quality outcomes in this area. The home listens to people and generally protects them form abuse by robust Safeguarding Adults procedures. There is a potential for people to be financially abused because of lack of knowledge of their overall financial status, the practice of paying staff expenses and providing for some of their own basic needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has recorded no complaints, regarding the care given to the people who live there since 2001. Two people said that they knew who to talk to if they were not happy and felt safe in the home. One person said that she would talk to staff and they would ‘help her’. The complaints procedure is included in the Service User Guide and is produced in a ‘user friendly format’. Two of the residents are able to tell people if they are not happy and staff explained how those who are not able to express themselves clearly, verbally, show their unhappiness or distress. They described examples such as facial expressions, body language and unusual behaviours. The Commission for Social Care Inspection has received no information with regard to complaints or Safeguarding Adults issues about this service. The manager confirmed that physical interventions are not used in the home and no incidents have been recorded. None of the behavioural guidelines 11 Allenby Road DS0000046683.V330911.R01.S.doc Version 5.2 Page 17 describe the use of physical restraint. The manager confirmed that there had been no safeguarding adults issues since the last inspection. All staff have received Protection of Vulnerable Adults Training, which are shown on the training records and confirmed by staff. A senior staff member advised that she was about to complete a more ‘intense’ Protection of Vulnerable Adults Training course. Two staff were clear about how they would protect the people in their care, described how to use the Protection of Vulnerable Adults procedure and their moral and legal responsibilities. The home has an organisational Protection of Vulnerable Adults procedure, a whistle blowing policy and adheres to the multi-agency Protection of Vulnerable Adults procedure. Four of the resident’s finances are dealt with by the Court of Protection and two have family members as appointees. Five of the residents are not aware of their overall financial status or their income /expenditure. The manager is unable to check whether people are receiving the correct benefits or support them to make informed choices about expenditure. The manager applies to the Court of Protection if people want to make any larger purchases such as holidays or clothing and the application can be vetoed by the care manager, without discussion or review. The manager agreed to take up as an issue at the residents’ annual reviews. The current poor practice is for residents to pay directly for staffs’ meals/drinks if they are accessing the community, there are also examples of them paying for bedding and equipment to meet their disability needs. It was discussed with the manager that this is a system with the potential to be abusive and/ or discriminate for or against residents’, depending on their financial status. This arrangement is not included in contracts/statements of terms and conditions. 11 Allenby Road DS0000046683.V330911.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 and 30. People who use the service experience good quality outcomes in this area. The home is well maintained and is a suitable and comfortable environment for the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All areas of the building were seen, they are of a high standard of cleanliness and well decorated. There are development plans to make the kitchen and dining area one space so that people who use the service will be more able to participate in meal preparation and other activities. Peoples’ bedrooms were reflective of taste and personality and designed/organised to meet diverse individual needs, such as physical, health and sensory difficulties. Bathrooms and toilets are also designed to accommodate special needs (including ceiling hoists), there is a development 11 Allenby Road DS0000046683.V330911.R01.S.doc Version 5.2 Page 19 plan for a ‘wheel in shower’ to be provided for the additional comfort of a resident who uses a wheelchair. The laundry is well organised and has the necessary equipment to deal with cross infection. There is an infection control policy and a proper system for the disposal of ‘soiled’ items. 11 Allenby Road DS0000046683.V330911.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 and 35. People who use the service experience good quality outcomes in this area. The staff team are competent and well qualified. The home makes sure they are able to meet the needs of the people who live there, by offering good training opportunities and support for their personal development. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Recruitment records are held at the head office of the organisation but they are available for perusal, if required. The home holds forms which note that all the necessary records are retained in head office, the manager confirmed that she has seen all the information, including two written references and Criminal Records Bureau checks for all staff. Two staff confirmed that they had all the necessary checks but there have been no new staff appointed since December 2005. Staff members have transferred from other homes within the organisation but have not changed employers. The Pre-inspection Questionnaire noted eight of ten support staff with N.V.Q 11 Allenby Road DS0000046683.V330911.R01.S.doc Version 5.2 Page 21 level 2 or above, this has reduced to 70 because a long-standing member of the team has recently retired. Training records showed thirty-seven courses attended by staff in 2006/07. The organisation has a personal development plan for staff who are appraised on an annual basis. Two staff confirmed that there are good training opportunities and said that it is a stable staff team. The training plan includes understanding diversity, which all staff are to attend. A survey noted that ‘communication between staff can be poor’. Staff acknowledged that there were some issues that the team is working through and these were noted on the staff meeting minutes (such as to improve communication within the staff team). The staff spoken to the deputy manager and the registered manager confirmed that the team is working to improve communication and team cohesion. Supervisions are generally completed monthly, staff confirmed that they receive regular supervisions. Staff meetings are held regularly (monthly), minutes are kept and the content showed that all necessary topics are covered including recognising what improvements need to be made. There are a minimum of three staff (two females and one male) on duty during daytime hours, the manager or deputy are generally extra to the care rota. The home works with a system of having a staff member being the ‘designated responsible person’, they take responsibility for the shift and the day-to-day routines, they receive training for this role. Staff were very knowledgeable and involved in the provision of good quality care for the service users. One talked at length, about the importance of consistency for residents and one spoke of the necessity for good communication between staff, both felt that there have been some positive improvements. The General Practitioner noted that ‘staff communicate clearly’ but there is ‘not always a senior available to talk to’. Other surveys said ‘staff are friendly and helpful’, ‘staff care of residents is exemplary’. One resident said the staff ‘are good and they will help you’, she also described the role of her key worker and said that her last key worker had retired. Another resident said she ‘liked the staff, they are always around to help’. 11 Allenby Road DS0000046683.V330911.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 and 42. People who use the service experience good quality outcomes in this area. The home is effectively managed and people are kept as safe as possible within the home. The home monitors the quality of care that it gives and has some development plans to improve the outcomes for the people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager of the home is appropriately qualified and experienced, she is, currently, overseeing two homes. She spends approximately three days per week at Allenby road. A deputy manager has been in post since December 2006, he works all his 11 Allenby Road DS0000046683.V330911.R01.S.doc Version 5.2 Page 23 hours at the home. The deputy manager and the registered manager are leaving the service during June 2007, a new manager has been appointed but there is no published date for her to take up post, plans are in place for the interim management of the home. Staff spoken to said the management team ‘do their best’ but felt that it would be nice to have a full time manager and some stability with management. The home has several quality assurance systems in place, these include regular regulation 26 visits, a three monthly audit of the home by the manager or deputy (the audit includes a progress report for each individuals goals /aims as identified at review) and surveys sent to other professionals, families, advocates on a three monthly basis. Tennant’ meetings are views of residents are taken form these and the individuals’ annual reviews. An annual service plan is produced and this is in the form of priority action plans in the areas of residents, staff, partners and environment. Monitoring of the progress of the plan may be more robust if the results of actions were cross-referenced and recorded against the plans when completed or priorities met. All health and safety records seen are up-to-date and staff Health and Safety training refreshers are completed as necessary Accident/incident forms are fully completed and state the action taken to minimise their recurrence. Staff members demonstrated a good knowledge of Health and Safety issues. 11 Allenby Road DS0000046683.V330911.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 2 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 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 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 X X 3 X 11 Allenby Road DS0000046683.V330911.R01.S.doc Version 5.2 Page 25 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 YA23 Regulation 13.6` Requirement To review the practice of service users paying out of pocket expenses for staff members to ensure the financial security and equity of those service users. To review the practice of service users purchasing items to meet their basic needs to ensure that the providers are fulfilling their legal obligations. Timescale for action 01/09/07 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. Refer to Standard YA23 Good Practice Recommendations To support service users to gain knowledge of their overall financial status, including details of their income and expenditure. 11 Allenby Road DS0000046683.V330911.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 11 Allenby Road DS0000046683.V330911.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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