Inspection on 03/07/06 for 123 Calmore Road

This inspection was carried out on 3rd July 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

123 Calmore Road 03/07/08

123 Calmore Road 10/01/06

123 Calmore Road 16/05/05

123 Calmore Road 08/12/04

123 Calmore Road 13/07/04

123 Calmore Road 09/03/04

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Fairways

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

CARE HOME ADULTS 18-65 123 Calmore Road Totton Southampton Hampshire SO40 2RA Lead Inspector Mrs Pat Hibberd Unannounced Inspection 3rd July 2006 09:15 123 Calmore Road DS0000012374.V297251.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 123 Calmore Road DS0000012374.V297251.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. 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 123 Calmore Road Address Totton Southampton Hampshire SO40 2RA 023 8066 8139 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) www.new-support.org.uk New Support Options Limited Joyce Mary Hopgood Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 Brief Description of the Service: 123 Calmore Road is registered to provide care and accommodation for six adults with learning disabilities. The home is arranged in two bungalows, with access between them via an office. Staff work in both bungalows, but service users are encouraged to live separately. The service is provided by New Support Options and the building is owned and maintained by Swaythling Housing Association. The home has three cars and there is a local bus stop directly outside the home. The current fees are £1292.75 -£1297.80 per week. Fees do not include hairdressing costs, chiropody, toiletries, basic costs of holidays and use of house car. 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. All key standards were inspected on this occasion. The fieldwork inspection took place over four hours and the inspector was able to tour the home, view a number of bedrooms and the communal areas. Discussions were held with the Home’s manager and three permanent staff members. The inspector spoke with one service user and spent time observing staff interaction and support with service users as detailed in care plans. Two service users’ care plans were viewed. Due to the complexity of their needs, the service users were not able to comment on the service provided although discussions held with the registered manager and three members of staff as well as sampling of records, files and observation during the visit contributed to the findings of this report. Additional information was supplied within a pre-inspection questionnaire completed by the Home’s manager. Prior to the inspection two service user and three relative comment cards were received by the commission of which views expressed as to the service provided by the Home are included within this report. There were three areas of improvement identified of which details can be found in the main body of the report. What the service does well: What was evident throughout the inspection was the commitment by the staff team to provide a homely, comfortable lifestyle for individuals’ accommodated despite their diversity of needs. Staff demonstrated a thorough awareness of service users’ needs and were observed following care plans and guidelines ensuring risks were minimized without compromising service users independence. Activities and diet are well organised, reflecting service user likes and dislikes as much as possible, while promoting healthy eating. There are systems in place which ensure that communication, recording and information sharing is effective, meeting service user needs, and that service users where able are involved in the running of the home. The Home’s manager demonstrated a thorough knowledge of the service user’s accommodated and was supporting staff effectively. 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 123 Calmore Road DS0000012374.V297251.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 123 Calmore Road DS0000012374.V297251.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are clear care planning systems in place ensuring prospective service users needs and aspirations are assessed. EVIDENCE: There have been no new admissions to the Home since the last inspection and for a number of years. From two files viewed and discussions with the Home’s manager Ms Hopgood it was evident that all service users have an assessment of their needs and aspirations for the future through a “vital information profile “ and an “essential lifestyle plan”. One service user has a “ circle of support “ which enables people important to the individual to get together and help decide what support is required. Staff spoken to were aware of the information held in files and were able to describe care and support needs for service users accommodated; both in house and the community and, how they were being met. 123 Calmore Road DS0000012374.V297251.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 at least once during a 12 month period. 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. There are care planning and risk assessments in place which provide staff with the information required to meet the needs of service users and enable service users to make decisions about their lives. EVIDENCE: During this visit, two service user files were viewed. It was evident that much work has been undertaken by the manager alongside staff, the community learning disability team and service users to ensure care plans and guidelines relating to support needs of individuals are detailed and relevant to their support needs. For example care plans included details of all areas of service users assessed need, including health action plans, community and activity programmes and details of personal support needs and approaches to be taken in the event of particular behaviours. In discussion with the manager and three staff it was clear that the care plans and guidelines are referred to on a daily basis alongside good systems of communication that have been developed to continually inform the reviewing process. Communication systems include shift “handovers”, completion of daily records and informal discussions. Person centred planning is the focus of all work undertaken with 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 10 service users. Advocates are also involved in the service to ensure that the rights of service users are upheld. In one of the files viewed it was further evident that the cultural needs of the service user had been identified in consultation with family members and clear guidelines produced in relation to dietary requirements, religious practices and festivals. Due to the complexity of the needs of service users it was difficult to ascertain whether they would have any comprehension of a care plan in any format although pictures, objects of reference and sign language appropriate to the individual were seen to be actively in use in the Home. Staff confirmed that they had attended a range of training including makaton sign language and autism awareness. One staff member indicated that some of the service users had their own individual way of communicating which had been documented in their care plans giving guidance to staff as to how the individuals expressed their feelings. The staff member further explained that this enabled staff to be aware of “triggers” that service users may display when they were feeling unhappy or agitated and support needs of the individual. From discussion with staff it was clear they had a good understanding of individual’s’ needs, and were seen to interact appropriately. Choices and decisions made by service users were seen to be well supported by staff, and in accordance with current risk assessments. For example on the day of the inspection it was extremely hot with warnings being given of a heat wave. Staff were seen to be providing service users with regular drinks, shade in the garden and sun tan lotion was being applied as appropriate. 123 Calmore Road DS0000012374.V297251.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are involved in a range of activities, their dietary needs are being met and relationships and rights are promoted. EVIDENCE: A range of activities has been developed for each service user, based around their known interests and preferences. Two files viewed included a variety of activities, including group and one to one opportunities, or in some instances two to one when accessing the community, based on service users’ care plans and risk assessments. The Home is divided into two bungalows with each having a TV and video and a garden of which all service users were seen to access independently and enjoy during the inspection. The day service provision has recently changed for some of the service users with the monies allocated by Social Services to the individual rather than through a block contract with an external agency that had formerly been the case. In discussion with the Home manager and the staff member designated to organise service users’ activity programmes they explained that this has enable much more flexibility and choice for the service user. Service users take part in individually organised day activities such as music and movement, 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 12 swimming, baking, horse riding and trampolining. Two of the service users attend local college classes in arts, crafts and cooking. Details of the support service users require to take part in these activities are included in their care and support plans. Two feedback forms received from service users indicated that they were generally happy with the care and activities provided with three relatives commenting that they were welcomed into the Home and can meet with their relative in private if they so wish. The Home has produced their first newsletter that will be sent to relatives, other Home’s within the Organisation and Social Services. Service users have contributed where able and willing to do so. Staff were observed engaging with service users, either supporting a service user in the garden, explaining when they would be going home to visit their family, or taking time to support them with a meal. Discussion with staff confirmed that staffing levels have improved since the allocation of additional hours for individuals and that activities are not normally cancelled. Care plans sampled identify regular family contact and encourage responsibility for daily living tasks, dependent upon service users’ abilities. Staff advised that encouragement of these skills is promoted, no matter how small, and that visitors are encouraged into the home at any time. One service user has a key to their bedroom. Menus seen indicated that a varied diet is provided, and alternatives are always available. One of the care plans viewed identified specific cultural dietary needs that had been discussed with the individual’s family. Staff spoken to demonstrated their understanding of the guidelines produced. There was a large bowl of fresh fruit in the kitchen and staff confirmed that fresh vegetables are generally available. Due to the needs of individuals it was difficult to ascertain whether service users were happy with meals provided. However, staff confirmed that all were able to express their views in their own way and an alternative would always be offered. 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. 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. Service users are supported with their own personal and health care needs, with appropriate assistance from relevant professionals. The medication system in the Home is well managed, which protects service users. EVIDENCE: Documentation viewed indicated that health care needs are met, with appropriate support from staff to attend various appointments where necessary. There are clear guidelines for staff within care plans on how to support personal care, based on the individuals’ preference where known. Health needs are closely monitored, with the support of the Community Learning Disability Health Care team, referral to appropriate specialists as seen within files, and specialist training of staff. Training includes autism awareness communication and a 7-day new induction programme for all new staff and existing staff titled “New Approach”. This covers a range of needs including healthcare. Files viewed confirmed that service users have access to a local GP, dietician, speech therapist, community dental and chiropody services, and optician. Files further indicated that due to the needs of individuals staff require training in “restraint”. This has been provided for most staff. bMedication records were viewed and were up to date with medication 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 14 appropriately stored. One staff member explained that the shift leader would hold the key to the medication cupboard. The majority of staff are trained in the administration of medication and receive six monthly updates. Prior to a new recently trained member of staff administering medication they would be observed on three occasions by a senior staff member to ensure they are confident and competent with the practice. Care plans viewed detailed guidelines for administering PRN (as required) medication including preventative measures staff need to take prior to administering PRN medication. Staff spoken to were able to explain how the guidelines are put into practice and the importance of ensuring they were aware of how to support an individual and “triggers” that may cause a service user to become upset and agitated including feeling unwell. 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A complaints policy and procedure and alternative systems are in place to ensure that service users and their relatives concerns are addressed. Staff have a good understanding of adult protection issues, which protects service users from abuse although further training in restraint needs to be undertaken to improve the protection of staff and service users. EVIDENCE: The home had a copy of the New Support Options complaints procedure in place and displayed in the home. At the last inspection the manager reported that work was currently underway to make this document available in an accessible format, to make it easier for service users to understand. This work has been completed and a pictorial format of the complaints procedure seen in the communal area of the Home. Two service users comment cards received indicated that they would talk to staff, the visiting advocate or relatives if they were unhappy with any aspect of service provision. The key worker system in place allows staff to build close relationships with service users to enable them to identify indicators or behaviour patterns when a service user is unhappy with staff demonstrating their knowledge and experience of service users likes and dislikes throughout discussions held during the inspection. Three relatives indicated in comment cards received by the commission that they did not have a copy of the complaints procedure. However, in discussion with the Home’s manager she confirmed that this has been raised in previous inspections and copies had been sent to all relatives. It was agreed that these would be given to relatives again and discussed verbally as to the procedure that would be 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 16 followed if they were dissatisfied with any aspect of their relatives care. A complaints book was available and showed that there had been two complaints since the last inspection. One had been resolved and one was ongoing but being appropriately dealt with by the service manager and Home manager. Staff have received training in adult protection and demonstrated a good understanding of adult protection issues and reporting procedures, and confirmed they receive clear direction and training on the approach to be adopted when presented with challenging behaviour. Care plans and training records confirmed this. However, following a recent adult protection investigation involving two service users who experience difficulty living together in the Home and, present some “challenges “ to each other and staff it was concluded that alternative training that is currently available in the means of “restraint” may be more appropriate. This training has not as yet been arranged. The Home’s manager agreed that this would be done as soon as possible as the agreement was made at a meeting held by Social Services in February 2006.An area of improvement was identified to this effect. In discussion with one staff member they further confirmed that they had not had any training in restraint. However, they were aware of approaches to be taken as detailed in care plans and from discussions held with all staff that guidelines were being followed. For the protection of staff and service users the Home’s manager agreed that staff needed to have the relevant training and this would be addressed and the commission advised accordingly. There have been a number of regulation 37 notices received by the commission relating to incidents between service users although generally these are well managed by staff with appropriate support being provided by the Health Care Team. 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a home that is safe, clean and maintained to a reasonable standard. EVIDENCE: The requirement made at the last two inspections to replace the work surfaces, cupboards and drawers of the kitchen in bungalow A has been complied with. A recent follow up visit by the Environmental Health officer deemed the kitchen fit for use. However, on the day of inspection a gas installation engineer was visiting the Home, as one of the gas burners was faulty. The Home manager indicated that this would be mended or the gas hob replaced. This will be followed up at the next inspection. The rest of the home was generally well maintained with a door in bungalow B having been replaced and painted and some areas of the walls in bungalow B re-painted. Staff spoken with said they wanted to support the service users in bungalow B make the rooms more homely, although they were aware that the needs of the service users meant they would need to consider this carefully. There is an ongoing maintenance programme in place. Both of the bungalows smelt clean and fresh. 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 18 At the last inspection one of the toilets in bungalow B was also being used to store activity items, that were being used as part of intensive interaction work with one service user in conjunction with the specialist health team. This has now been cleared and alternative storage found. The toilet door was also being kept locked. Service users can now access this. There are no service users who have a physical disability with all areas of the Home accessible including the garden. There is a separate laundry with one staff member able to explain the policies and procedures relevant to safe practices and their knowledge of Control Of Substances Hazardous to Health (COSHH). 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home is supporting staff to achieve suitable qualifications and provides good training and sufficient staff to meet the needs of service users. Service users are protected through robust recruitment practices. EVIDENCE: The Home’s staff team have undertaken a range of training to ensure consistency of care, and a level of competency to ensure service users needs are met. From observation during the inspection it was evident that staff have an excellent knowledge of service users needs and have built good relationships that enable them to communicate effectively. A pre inspection questionnaire received prior to the inspection indicated that 40 of the staff team have already achieved a National Vocational Qualification (NVQ) to level 2 standard or above and had undertaken a range of training relevant to service users accommodated including food hygiene, health and safety, autism, emergency treatment updates, path planning and communication. From records seen, and discussions held with staff and the Home’s manager new staff are required to complete a thorough induction training programme prior to working in the home, including agency staff, to ensure that they have the skills to support service users. As previously referred to there is a new induction programme in place that reflects changes in the Organisation and the 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 20 needs of service users with a learning disability. The skill mix of staff is wide ranging to meet the diverse needs of service users. With the exception of alternative “restraint” training the manager indicated that training updates were all current, and from two staff files viewed this was confirmed. Three staff indicated that training is plentiful and accessible, and training needs are identified at monthly supervisions with either the manager or a deputy manager. The Organisation has produced a new training directory with further training planned to include SCIP, autism and ongoing NVQ training. Three members of staff spoken with said they felt well supported by their line manager, capable and confident in their roles and that the manager was approachable and accessible. Staff meetings are held regularly, and both felt they are fully informed and can contribute to the running of the service. Two staff records viewed indicated that a thorough recruitment process is undertaken by the Organisation with all staff having undertaken the appropriate checks prior to being employed in the Home. Bank staff are used in the Home although due to the needs of service users the staff would be regular staff that knew the service users. Staff spoken to indicated that there are generally sufficient staff on duty with the rota confirming that there are four staff on duty between 7.30am and 10pm and one waking and one sleep in staff member on duty at night. Service users also have additional one to one hours which amount to 80 hours a week and are used at times to meet individual needs and to reflect agreements reached at a recent adult protection regarding two service users in the Home. There have been no staff resignations since the last inspection with staff expressing that the moral in the Home has improved. 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. 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. Leadership provided by the manager ensures that outcomes for service users continue to improve and that staff and service users are involved in the running of the service. The health and safety practices in the home promote the welfare of service users. EVIDENCE: The registered manager, Ms Hopgood, has been in post for a number of years. She has a wealth of experience in working with the service users accommodated and from comments made by staff it was evident that Ms Hopgood is approachable and supportive, and interaction observed with staff and service users was very positive. Systems have been developed by the manager to ensure that staff are fully informed of service users needs, and appropriate risk assessments have been regularly reviewed to ensure the welfare of both staff and service users. Senior managers within the Organisation visit the Home on a regular basis with an internal quality audit system in place to seek the views of staff, sample 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 22 training and maintenance records, view the environment and observe care practices. The Home has recently completed a survey with service users, called the “10 big questions”, which New Support Options has introduced. The results of this survey have now been produced and have contributed to service users’ person centred plans and the development plan for the home. From the document produced it appeared that service users generally felt that staff did listen to them, they had a say in the running of their Home, generally had choices and knew how to complain or to whom. All had a care plan which generally reflected their needs and people to talk to about their care. The Home has copies of the Organisations policies and procedures of which staff indicated they had seen and were kept updated as to any changes by the Home’s manager. Appropriate systems are in place to ensure that health and safety and infection control practices and procedures are up to date and well maintained. Information supplied in the pre inspection questionnaire indicated that equipment and systems in the home are regularly serviced and well maintained . One area of improvement was identified and related to fire evacuation risk assessments being undertaken for all service users. These must be shared with staff and kept under review. In discussion with the Home’s manager and the staff it was evident that there is an evacuation procedure for the Home but the needs of individuals whilst verbally discussed as a staff team have not been formalised and documented. 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 X 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 24 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. 2. Standard YA23 YA42 Regulation 18 13 Requirement Staff must undertake alternative “restraint” training. Timescale for action 03/08/06 Fire evacuation risk assessments 05/07/06 must be undertaken of all service users and shared with staff. These should be kept under review. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 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 123 Calmore Road DS0000012374.V297251.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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