Inspection on 01/08/06 for 17 Norton Avenue

This inspection was carried out on 1st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

17 Norton Avenue 17/02/06

17 Norton Avenue 08/08/05

17 Norton Avenue 14/03/05

17 Norton Avenue 09/08/04

17 Norton Avenue 26/01/04

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

CARE HOME ADULTS 18-65 17 Norton Avenue Burslem Stoke-on-trent Staffordshire ST6 7ER Lead Inspector Mr Berwyn Babb Key Unannounced Inspection 1 August 2006 12:22 17 Norton Avenue DS0000008216.V306258.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 17 Norton Avenue DS0000008216.V306258.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. 17 Norton Avenue DS0000008216.V306258.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 17 Norton Avenue Address Burslem Stoke-on-trent Staffordshire ST6 7ER 01782 819870 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) Choices Housing Association Limited Mrs Sheena Morton Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6), Physical disability (6), of places Physical disability over 65 years of age (6) 17 Norton Avenue DS0000008216.V306258.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents with either Learning Disability (LD or LD(E)) category may also have a Physical Disability (PD or PD(E) Date of last inspection Brief Description of the Service: Norton Avenue is a purpose built, single storey home situated in its own grounds in Norton, a residential area of Stoke-on-Trent. It is one of a group of homes managed by the Choices Housing Association, which is a wellestablished provider of care for people with learning disabilities in North Staffordshire. Norton Avenue is registered to provide care for six adults with a learning disability. It also has a variation to accommodate six persons with a physical disability. The current resident group of five females and one male range in age from 48 to 78 years, although most are over 60 years old. All of the residents have previously lived in long stay hospital settings. Most came to this home when it first opened approximately 12 years ago. The home is conveniently situated to access local transport routes and a range of amenities. A disadvantage with its location is its position on a very steep road, as several of the residents now require the use of a wheelchair to go out. The home has access to its own transport provided through the company. There have been no major structural changes since the last inspection. This report follows the younger adults format, as it was the opinion of this inspector that those standards were more pertinent to the residents of this home, as their primary needs remain those associated with Learning Disability, and not old age. 17 Norton Avenue DS0000008216.V306258.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the Key Unannounced inspection for the 2006/2007 year. When the Inspector arrived there were two sets of tradesmen in the home, one fitting guards to radiators in the bathroom, and one from the Choices Handycare Scheme who was carrying out minor repairs to one toilet where the screws fixing it to the floor had snapped, causing it to move and damaging some boxing to the pipes. He was also making good the damage done to this boxing. All residents were in the house at the time the Inspector arrived, though one left shortly afterwards with a member of staff to go to the local superstore to do the weeks shopping, leaving two members of staff on duty in the home, until 12:00 o’clock, when Mrs Sheena Morton the registered care manager arrived to start her shift of duty. One person was working as supernumerary during her induction period, and at all times there were sufficient staff to meet the assessed needs and choices of residents. The inspector toured the internal environment and interacted with all residents. There were two members of staff on maternity leave, and their shifts were being covered by other members of staff working extra duties. A lot of time during this inspection was with Mrs. Sheena Moreton, the Care Manager and discussing the implications of the report by the Fire Officer dated the 13th April 2006 and the need to get professionally qualified advise in order to respond to this, and to use it as an opportunity for positive forward planning to reduce the possibilities of confusion over the necessary procedure, should a fire break out. At this point in the process, although individual risk assessment had been generated, the individual evacuation procedures had not been formulated, and a major problem area identified during discussion was how the single member of staff on duty at night would be able to evacuate the resident requiring a hoist to lift her out of bed and into her wheelchair, when the risk assessment for that person states that there should be two people to operate this hoist. 17 Norton Avenue DS0000008216.V306258.R01.S.doc Version 5.2 Page 6 What the service does well: 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. 17 Norton Avenue DS0000008216.V306258.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 17 Norton Avenue DS0000008216.V306258.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): 1,2,3. The judgement of the outcome for this group of residents was good. This judgement was made using available evidence including a visit to the home. It is based on the regular update of the Statement of Purpose and the Service Users Guide, the use of full multi-agency assessments prior to admission, and making information about the home available to prospective residents through a medium with which they can engage. EVIDENCE: The inspector was able to view the most recent draft for renewing the Statement of Purpose, and noted that this contained new photographs of people and the environment, a record of staff changes, a much improved format which like the improved Service User Guide made it much slicker and more user friendly, with bold typing and pictorial versions to assist people with challenged communication skills, and also done in a summary form. During the afternoon the Inspector spoke at length to one resident (H) and then took part to sift through her personal care plan as a result of which he can verify that a very full and proper multi-agency assessment of her needs and of her personal choices was made as a basic tool to measuring the suitable of the home to provide appropriate care for her. (H) told the Inspector ‘I used to come and visit the home before I moved in to see my friends here, and I liked it, and was glad when I came’. 17 Norton Avenue DS0000008216.V306258.R01.S.doc Version 5.2 Page 9 She had been able to discuss with her social worker and the care workers in both this home and her previous placement, the way that this would be better able to meet her particular assessed needs, as it is a single storey building and therefore all on one level. 17 Norton Avenue DS0000008216.V306258.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, and 9 The judgement of the outcome for this group of residents was good. This judgement was arrived at using all available evidence including this visit to the service. EVIDENCE: The inspector was able to review a sample of the care plans for the residents as detailed below: HH. There was a very detailed personal care programme for this resident. The health module contained matrix that included both a record of regular appointments, and those that had been generated because of changes in her health or care. There was reference to the physiotherapy she required, both for assessment of established and emerging needs, and for the provision and advice to staff concerning adaptation of that result from this assessed need. Tertiary health appointments such as dentists, chiropodists, and opticians, where recorded together with the outcome of these visits. 17 Norton Avenue DS0000008216.V306258.R01.S.doc Version 5.2 Page 11 Reference was made to the social life that the resident enjoyed, including visiting her boyfriend every two weeks and making phone calls to him in-between these times. There was also reference to reminiscence sessions once a week with the key worker, and to trips out to purchase clothing reflected her gender and her sexual orientations. She was receiving one-toone input from her key worker and was able to confirm that she enjoyed having her nails painted by this person. As well as visiting her boyfriend, she had regular contact with her sister and had recently returned from a holiday in the caravan in Rhyl that Choices provide for their residents. Her key worker had supported her to enjoy visits with her boyfriend and with her sister. In the comments card returned to the CSCI before the inspection she had said: “I like living here, the staff and the other residents are OK”. The only thing that she did not like was another client who shouts, and interestingly that client had noted that the one thing that she didn’t like was this client. HH moved to this house from another owned by Choices, because of a reduction in her mobility that had led to an increase in a recorded number of falls, and staff were observed throughout the course of the inspection being vigilant to see that she used the appropriate walking aid so that she could continue to move around the house, rather than restricting her freedom of movement. Resident VJ. In the care plan for VJ, the inspector found it contained detailed input as for HH, together with further details of the risk assessment because of her greater immobility, including not just the appropriate type of wheelchair, but also assessment of the effects of being in a chair all of the time. The risk assessment for hoisting VJ from her wheelchair to the bed showed that two members of staff needed to be available to do this, and the Inspector spoke with the Care Manager about the consequence of this for VJ during the period between the end of the evening shift and the beginning of the morning shift, when there was only one member of staff. This will be explored more fully on the later section in reference to fire risk, but it is a matter of concern that this lady cannot choose to be up at any time during the night should she wake up and want to be so. 17 Norton Avenue DS0000008216.V306258.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. The judgement on the outcomes for this group of residents was good. This judgement was made using available evidence including this visit to the home, and is based on findings that the life-style for the residents was enhanced to provide them with the maximum opportunity for activities, community presence, family and friendship networking, and they were receiving a healthy and pleasant diet. EVIDENCE: From speaking to one resident the Inspector became aware that residents were able to take part in age and personality activities. Key workers were taking people out to do shopping for those things they were able to indicate that they desired, the consequence of which was that residents were able to demonstrate their chosen individuality in things that they wore, they ate, and the presentation of their personal space. The Inspector also became aware from observation, that detailed work was being carried out with a particular service user, to give her continuous access to what was age appropriate, but not to the extent that they were imposing socially constructed norms upon her choice to take comfort from things of childhood which she valued. 17 Norton Avenue DS0000008216.V306258.R01.S.doc Version 5.2 Page 13 During the Inspection one service user was out visiting retail establishments in the local community, and the Inspector was able to establish through observation of care recording, that considerable effort was put into ensuring that even the least mobile resident was able to maintain a community presence. This particular resident did not appreciate having a stranger in the home, something she indicated verbally with some emphasis, so unfortunately her comments cannot be recorded. However her care records showed that she was assisted to go shopping at least once a week to purchase fresh flowers, which she much enjoyed having around her room and the home. Arrangements had been made with a local taxi firm who have an adapted vehicle, that can accommodate her wheelchair, and which allowed her to get out of the house and travel medium distances, rather than being confirmed to a radius that was limited. One resident told the Inspector: “I go and see my boyfriend”. In her care plan it was also stated that she both visited, and was visited by her sister at least once every month. The relatives of another resident had programmed in a regular weekly visit, to coincide with an activity which she does not take part in, so that they could enjoy the privacy of one of the communal rooms[otherwise deserted at this time] rather than having to retire to her bedroom. An organised activity that took place during this inspection was the visit of the Keep Fit lady, who had designed programmes to encourage the maximum participation of each individual resident in the home, rather than this being a group activity from which some people got no benefit. The Inspector was able to observe a medication round taking place and also to observe in the personal care programme arrangements for regular reviews on, at least, annual basis of the medication of each resident. This was done with the local GP as part of an annual health check that forms part of the programme designed by Choices, based on good practice of The British Institute for Learning Disability, and was in addition to participation in the “Well Woman” and “Well Man” clinics. One resident and one member of staff returned from a weekly food shopping trip, and this caused a stir in the home as those who were able to, assisted in putting away the various articles, and commenting on those which had been purchased because it was known that they liked them. The Inspector and the residents had lunch and he was able to observe that personal choices were being catered for, and also that one resident was able to enhance her personal dignity, by assisting with the laying of the table, a task which she felt was appropriate for her. 17 Norton Avenue DS0000008216.V306258.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, and 20. The judgement for the outcome for this group of residents is good. This judgement was made using available evidence including this visit to the service, and it showed that there healthcare was of primary importance to the providers, and that training and advice was noted to be taken from the British Institute of Learning Disability. EVIDENCE: Some of the residents of this home required considerable intervention to ensure that their personal needs were met, and there were detailed instruction in the care plans as to how these should be undertaken, and to their personal preferences especially in reference to the gender of the carer who was assisting them. There is only one gentleman in this home, and he had made it know that he had no objections to being assisted by female staff. Currently there are no members of staff who are male, and the current vacancies arising from the two members of staff who are on maternity leave are being covered in-house so no problem arises there. 17 Norton Avenue DS0000008216.V306258.R01.S.doc Version 5.2 Page 15 None of the residents of this home have been assessed as capable of administering their own medication, and member of staff does this on their behalf. Clear protocols were in place for this, and there was a record of each person who was filling in the medication administration record, together with their sample signature to enable an audit trail to be followed should any problems arise. The schedule of training showed that appropriate training was given in the administration of medication. This included the effects that medications were seeking to achieve, as well as some of the more commonly found side effects, so that staff could watch out for them. The system of storage was the “M. D. S. Medipack” system, and when not in use medications were in a locked cupboard in the kitchen inside which there were four separate colour-coded further locked medication boxes, with the medication administration record on the front of each strip pack for each person kept within those boxes. Homely remedies were in a locked cabinet in the staff room and were restricted to such things as Paracetamol and topical creams, and this home operates a policy of not administering herbal remedies. As referred to previously in this report there was adequate evidence of the healthcare needs being met with each resident having access to hospital consultants, GP, and other clinical services as necessary, and regular tertiary appointments for such things as feet, eyes, hearing and teeth. 17 Norton Avenue DS0000008216.V306258.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, and 23. The judgement on the outcome of this group of resident was good. This judgement was made using available evidence including this visit to the service. It was based on the robustness of the training being given to staff, enabling them to recognise when residents had a grievance, and then to initiate the proper procedures, including setting in process the appropriate vulnerable adults protocol. EVIDENCE: The Inspector undertook a formal interview with staff during the afternoon, at which the subject of complaints and protection of vulnerable adults/abuse was discussed. The answers he received from her confirmed that the staff at this home were aware of those things, both acts of commission and acts of omission, constitute abuse. They also knew what to do when they had identified these. He was able to see from records that they had delivered appropriate training, and the member of staff confirmed this, and also added that they had received regular upgrades to enable her to put into practice those things, which were written, in the formal policies of Choices Limited. She correctly identified that anybody could abuse a resident at 17 Norton Avenue, whether it was a member of staff, another resident, a member of somebody’s family, or any other associate professional having access to the home. She pointed out that given the abilities of several of the residents, that staff had an initial roll as advocates for them, in that they use their knowledge of body language and of the known behaviour of residents to identify when there was something they were not happy about, and then actively engage with them to determine what this was. 17 Norton Avenue DS0000008216.V306258.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, 25, 26, 27, 28, 29, and 30. The judgement on the outcome of this group of residents was poor. This judgement was made using available evidence including this visit to the home. The outcome would have been better had it not been for items identified by the Fire Officer in his report of 13th April 2006, and the lack of an appropriate response to these. Additionally, there are still radiators in the rooms of residents that are neither of a low temperature surface manufacture, or protected by having guards over them. EVIDENCE: The Inspector discussed with the registered Care Manager many of their issues identified by the Fire Officer, and was extremely concerned that even after this period of time appropriate action had not been taken to meet these. He was also concerned that although there was a tradesman at the home placing two further covers over radiators, these were in the bathrooms where nobody currently resident at Norton Avenue spends time unobserved, rather than in their own bedrooms. 17 Norton Avenue DS0000008216.V306258.R01.S.doc Version 5.2 Page 18 Other than these concerns highlighted above, it was very pleasing to see that new carpet had been laid both in bedrooms of some of the residents, and in the hallways and passageways of the home. It was particularly gratifying to see the care that had been taken in laying this carpet, as a trip-hazard that had previously been identified in the last report, where an inspection cover was located in the middle of one of the passages, had been removed by the excellent work done by the carpet fitter. The room of each resident was large enough to allow for them to undertake both the things that they chose, and also for their personal and care needs to be met, including space to negotiate a hoist and a wheelchair. Each room was decorated differently, and it was established that there was a rolling programme of re-decoration for the home, with the care manager awaiting the arrival of the painters the following week. Photographs and memorabilia were prominent, reminding residents of their previous associations, interests, and family ties. The Choices handyman was in the home at the commencement of the inspection making running repairs to an item that had become damaged, and this entailed him replacing some of the panelling in the toilets. As previously mentioned there was a tradesperson putting in radiator guards, and these he fitted to the two bathrooms. During the inspection the care manager was concerned to source a new hoist for the resident who has previously been referred to, and was engaging in liaison with the appropriate healthcare professional about the type that was best for the needs of this resident, and then obtaining prices and delivery dates for different products from different companies. In the personal care profile of another resident reference was noted to the assistance that had been given by the Orthotics department of the local hospital, in the provision of suitable head and foot gear for this resident. During the whole of this inspection the home was found to be clean, odour free, comfortable, and extremely well maintained, and residents were moving around where they were able to do so, with a freedom of a place that was their own home. The construction of the home was in keeping with other buildings around, and was in no way stigmatised as being a nursing home. 17 Norton Avenue DS0000008216.V306258.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. The judgement on the outcome for this group of residents was good. This judgement was made using available evidence including this visit to the home. Evidence showed that staff was employed in sufficient numbers, and with sufficient training and experience to meet the assessed needs and choices of residents within the home. Further more the employer’s policies regarding recruitment of staff were found to be sound. EVIDENCE: Two staff were on maternity leave, and other members of the permanent staff of the home were covering their shifts. No bank staff had been used in the previous eight weeks, and the care manager was able to verify that all shifts were covered for the following six weeks. The recruitment policy of the Choices Housing Association was reviewed, and this was found to be extremely full covering the protection of the residents in the home, ethnicity and diversity, and a statement of commitment to work towards gender representation within their organisation. 17 Norton Avenue DS0000008216.V306258.R01.S.doc Version 5.2 Page 20 In an extremely thorough matrix of the training needs and training achievements of each individual member of staff was deposited with the Commission for Social Care Inspection, showing 93 had completed their formal training on protection from abuse, 57 had completed formal training on understanding the nature and causes of learning disability, a similar on understanding the aims and objectives of the home on confidentiality and 64 on understanding the practice of record keeping. 100 of staff had completed the training on the management and delivery of care support packages and dates were given for pieces of training being identified as deficient in individual carers employed in the home. 17 Norton Avenue DS0000008216.V306258.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. The judgement is that the outcome for this group of residents is poor. This judgement is made using available evidence including this visit to the home. It was based on the health and safety of residents not being properly catered for until those matters identified by the Fire Officer in his report of the 13th April had been attended to in a satisfactory manner, and on the continued deficit in the covering of radiators. EVIDENCE: It had already been mentioned under Standard 24 that much needs to be done to come to terms with the Fire Officer’s report issued at the beginning of April this year, from this Inspection that would obtain the services of someone professionally qualified to advise on the implications of this report. Individually tailored evacuation procedures must be formulated for all resident, and it is the responsibility of the registered person to ensure that these procedures are in place, and that staffing is always adequate to enable them to be carried out. 17 Norton Avenue DS0000008216.V306258.R01.S.doc Version 5.2 Page 22 Any adjustment to the admission policy of the home, as a result of meeting these recommendations needs to be clearly stated in the Statement of Purpose. In other areas looked at under this heading there were good indications to commitment of quality assurance, with regular Regulation 26 reports being sent to the Commission for Social Care, an Annual Plan was in place, and surveys had been sent out to families to obtain their view on the quality of the service being provided to residents in this home. There was evidence through written minutes of regular meeting being held for difference grades of staff, and other records showed that all necessary servicing had been undertaken for equipment, including water treatment servicing and risk assessments for Legionella. 17 Norton Avenue DS0000008216.V306258.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 3 2 3 3 3 4 X 5 X x X INDIVIDUAL NEEDS AND CHOICES Standard No Score 6 3 7 4 8 X 9 3 10 X x X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 3 x x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 4 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 4 3 X 3 3 X X X 2 x 17 Norton Avenue DS0000008216.V306258.R01.S.doc Version 5.2 Page 24 YES 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 YA24 Regulation 13.4 Requirement Pipe work and radiators must be guarded, or have low temperature surfaces. The registered person shall comply with Health and Safety requirements, in relation to ensuring that all appropriate steps are taken to complete work identified by the Fire Officer, to maximise the safety of residents from fire Timescale for action 31/10/06 2. YA6 13 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 17 Norton Avenue DS0000008216.V306258.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 17 Norton Avenue DS0000008216.V306258.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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