Inspection on 01/11/05 for 17 Woodrows Lane

This inspection was carried out on 1st November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

17 Woodrows Lane 17/09/09

17 Woodrows Lane 27/09/07

17 Woodrows Lane 17/10/06

17 Woodrows Lane 11/04/05

17 Woodrows Lane 05/10/04

17 Woodrows Lane 06/07/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 17 Woodrows Lane Bockings Elm Clacton On Sea Essex CO16 8DN Lead Inspector Pauline Dean Final Unannounced Inspection 1st November 10:15 17 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 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 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 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 Older People and 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 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 17 Woodrows Lane Address Bockings Elm Clacton On Sea Essex CO16 8DN 01255 433057 N\A 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) Mr Liyanage Lal Gunaratne Mrs Jennifer E Tubby Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (3) of places 17 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 6 persons) The total number of service users accommodated must not exceed 6 persons Three named persons, over the age of 65 years, who require care by reason of a learning disability, whose names were supplied to the Commission 11th April 2005 Date of last inspection Brief Description of the Service: 17 Woodrows Lane is a detached chalet bungalow offering care for six people with learning disabilities. The property is in keeping with the local community and is sited in a residential area. Accommodation is on the first and ground floors, with three single rooms on the first floor and one double and one single on the ground floor. Shower, bathing and toilet facilities are found on both floors. The ground floor single bedroom has an en-suite facility of a wash hand basin and toilet. Communal areas consist of a lounge, dining room and a small conservatory/lobby. There are gardens to the front, side and rear of the bungalow. There is a garage and a storage shed. The home is within walking distance of local shops, parks and schools. Public transport is close by and the home has their own transport. 17 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over one day in November 2005. This was the second inspection of the inspection year 2005 – 2006. Throughout the day there was discussion with the Registered Manager, Mrs Jennifer Tubby, the Assistant Manager and two care staff members. All of the residents were met at this inspection and during the visit they were spoken with. No visitors or relatives visited the home during the inspection. A tour of the premises was conducted at this inspection and both care and staff records were sampled. In addition some policies and procedures were sampled and inspected. Seventeen of the forty-three standards were inspected, of these ten were met with seven nearly met or not met. A total of thirty-five standards were inspected over the two inspections of the inspection year – 2005 – 2006, with some standards inspected on both occasions. What the service does well: What has improved since the last inspection? A greater variety of activities and college courses have been sourced for the residents. Three residents now attend college, regularly attending courses in Cooking, Arts and Crafts, Flower Arranging, Gardening, Music and Movement, Self-Advocacy, Computer Skills and Leisure Skills. All six residents had been able to have a holiday this year, three travelling to Spain and three in United Kingdom. Following on from the last inspection the Assistant Manager said that care planning documentation is gradually being entered on to the home’s computer. 17 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 6 This has already been found to enable easier reviews of care planning objectives and risk assessments. 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 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) 17 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5. Residents have individual written contracts. However, these did not clearly detail the terms and conditions, services and facilities available. EVIDENCE: Copies of residents’ contracts were sampled and inspected. Omissions were noted i.e. the contents of the contracts did not match those listed in the National Minimum Standards – Standard 5.2. Mrs Tubby agreed to review these contracts to ensure that they meet requirements. 17 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10. Residents know that information about them is handled appropriately to ensure that confidences are kept. EVIDENCE: Whilst care planning documentation was not inspected in detail at this inspection, the Inspector noted that word processing is now being used to collate information. Residents’ individual records are held on care planning files, which are held in the home’s office. These are kept secure and to hand at all times. 17 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 & 16. Residents are supported and enabled to have opportunities for personal development through the provision and promotion of appropriate leisure and training activities in the community. Their rights are respected and responsibilities recognised in their daily life, to ensure that they have 17 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 11 independence, choice and freedom of movement, subject only to restrictions detailed in their individual care plans. EVIDENCE: In the past year 17 Woodrows Lane has pursued and progressed access for their residents to attend college and training courses. Three of the six residents attend courses in Cooking, Arts and Crafts, Flower Arranging and Gardening, Music and Movement, Self-Advocacy, Computer Skills and Leisure Skills. All six residents had been able to have a holiday this year, three travelling to Spain and three in United Kingdom. In addition four of the six residents attend a weekly social club, with all six residents attending a monthly social club. Three residents were able to tell the Inspector of their holidays and one resident spoke of a recent club visit where they had won a raffle prize. On the day of the inspection two residents attended college. One attended for a whole day and the second had an afternoon session. Both spoke positively of their experiences at college. Four of the six residents are able to use public transport and all have bus passes. Two residents regularly use the local library borrowing CDs, DVDs and videos. Both the Registered Manager and the Assistant Manager gave examples of the ways in which residents’ rights are respected. Consideration had been given to residents holding their own key, but following discussion with two residents who were able to hold their key, they had decided that they did not wish to take this responsibility. Throughout the inspection it was evident that residents were able to choose whether they wished to be alone or in company. Residents took themselves to their rooms as they wished and were able to join in activities as they wished. Residents undertake household tasks. The Assistant Manager and the Registered Manager gave examples of how this is encouraged and promoted. One resident is responsible for cutting the lawn, whilst others are able to complete other household tasks such as hanging the washing out, mopping the floor and changing their bed linen. 17 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) 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. Residents’ healthcare needs are met within the home and records evidenced that they are supported to access healthcare professionals as needed. EVIDENCE: From discussion with the Registered Manager and the Assistant Manager the Inspector was informed of the ways in which they offer personal support to individual residents. The changing needs of residents had been considered and technical aids and equipment had been purchased to enable residents to have independence and mobility inside and outside the home. It was also apparent that residents are able to decide on the time they get up and the time they go to bed. This was subject to restrictions in their care plans and often revolved around college courses and activities. 17 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16, 18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 16, 18 and 35 (Older People) 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 & 23. Appropriate practices were in place to help ensure that residents’ views are listened to and acted upon, and their protection is promoted. Staff training, the awareness of the manager, policies and staff recruitment practices promote this. EVIDENCE: The home’s complaints procedure was inspected and was found to meet requirements. Mrs Tubby said that there had been no complaints since the last inspection. An adult protection policy and procedure was inspected and was found to meet requirements. Reference is made to Essex County Council Protection of Vulnerable Adults (POVA) Referral and a copy of the alert form is attached to the procedure. Both Mrs Tubby and the Assistant Manager had attended a local authority seminar on the Protection of Vulnerable Adults (POVA) guidance publications now available. 17 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) 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 & 30. 17 Woodrows Lane provides a safe, homely and pleasant environment, which was clean and comfortable. EVIDENCE: 17 Woodrows Lane offers easy access to the local community as it is situated in a residential area on the outskirts of Clacton on Sea. Local bus transport is nearby, with all the usual amenities of shops, leisure facilities and college/training courses in the area. 17 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 15 A tour of the premises was undertaken at this inspection and the accommodation was found to be clean, tidy, bright and free from offensive odours. Both the Registered Manager and the Assistant Manager said that decoration is planned for a ground floor bedroom and en-suite facility. This room was seen to be in need of decorating as it did not present as the other accommodation, which was light, bright and homely. The remainder of the home was well decorated and since the last inspection the home’s office has been decorated with additional cupboards and shelving added. Bedroom accommodation was seen to be personalised with residents’ personal belongings on display within their rooms. Following the last inspection, the Assistant Manager said that soft surface matting had been installed on the garden patio area during the summer months. This had proved very successful, providing a cushioned floor when a resident who was prone to fall had fallen. This surface has been removed during the winter months. The Assistant Manager said that this would be refitted following a detailed risk assessment next year, should it be required. Further aids and adaptations have also been introduced in the home following an assessment and consultation with an occupational therapist. In-house laundry facilities of a washer and dryer, domestic in character, are found on the ground floor in a utility room. Both the flooring and the wall surfaces are impermeable and are easily cleaned. Washing is completed during the day and at night. 17 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) 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, 33 & 36. Staffing levels and skills are appropriate to the needs of residents. Basic training courses help ensure that care staff are competent and qualified. Recorded supervision sessions have been introduced. A structured system of regular supervision sessions now needs to be introduced to help ensure that staff are well supported and supervised, to assist the residents. EVIDENCE: Mrs Tubby said that care staff are encouraged to attend basic training courses. Recently staff have attended a basic food hygiene course and four staff plan to attend a First Aid course. In addition, the Assistant Manager has enrolled on a distance learning National Vocational Qualification (NVQ) Level 4 in care and management and another care worker is looking to enrolling on an NVQ Level 17 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 17 2 in care. Both medication training and moving and handling training have been highlighted as training requirements for the home. From discussion with the Registered Manager and the Assistant Manager staffing levels were seen to be met. The Inspector was informed that staffing levels are continually reviewed to ensure that residents’ needs are met at all times. Additional care staff are rostered to enable residents to access local social clubs and activities, and attend collage courses. This was evident on the day of the inspection when a care worker accompanied a resident to a college course. Whilst supervision sessions have been introduced it was acknowledged that there is a need to introduce regular, recorded, structured supervision sessions. The Assistant Manager spoke of a recent supervision training course they had attended and it was acknowledged that there is a need to expand the current recording arrangements to ensure that they fully cover all aspects of the National Minimum Standards – Standard 36.4. 17 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) 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, 40, 41 & 42. Staff and residents are well supported by the home’s manager, who is handson and part of the care team of the home. An effective quality assurance and quality monitoring system is still required as analysis of completed questionnaires need to be completed. Omissions were found in some policies and procedures required to safeguard residents’ rights and interests. Overall 17 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 19 the records required to protect residents’ needs were found to be in place and some safety certifications held were found to meet requirements. EVIDENCE: As at the last inspection, Mrs Tubby said that she did not wish to undertake any further training such as National Vocational Qualification (NVQ) level 4 in care and management. The Assistant Manager confirmed that they had enrolled on a distance learning NVQ level 4 course and is hoping to commence this course in the near future. The need to plan the transfer of the managerial role in the home was discussed with the Registered Manager and an application for registration needs to be progressed by the Registered Provider immediately. An effective quality assurance and quality monitoring system based on seeking the views of residents still has to be implemented. Advice was given as to how this could be progressed and how the results could be published and made available to residents and their representatives. Copies of policies and procedures were sampled and inspected and they were found to meet requirements. Records required by regulation for the protection of residents were seen to be in order, with the exception of the Regulation 26 visit by the Registered Provider. This statutory requirement is outstanding from previous inspections. A Notice of Immediate Requirement has been left with the home requiring the Registered Provider to submit a Regulation 26 visit report by 30th November 2005. Mrs Tubby had sought further safety certification for gas safety. This was had been highlighted at the last inspection. Gas safety certification was seen to be in place, dated August 2005. Further maintenance certification is required for the mobile hoist. Record keeping relating to hot water temperatures needs to be developed to include all hot water outlets used by residents. A copy of Employer’s Liability Insurance was seen on display and it was current. 17 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 X 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 X 35 X 36 2 CONDUCT AND MANAGEMENT 37 2 38 X 39 2 40 3 41 1 42 2 43 X Standard No 6 7 8 9 10 LIFESTYLES 11 12 13 14 15 16 17 Score X X X X 3 3 X X X X 3 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X X 17 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 21 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 YA5 Regulation 4, 5 Timescale for action The Registered Manager must 19/12/05 develop and agree with each resident a written and costed contract/statement of terms and conditions between the home and the resident. The Registered Manager must 19/12/05 ensure that residents are supported by competent and qualified staff. This is with particular regard to medication, moving and handling and NVQ training. Requirement 2 YA32 18, 19, 3 YA36 17, 18, 24 The Registered Manager must 19/12/05 ensure that all staff receive the support and supervision they need to carry out their job. 18 The Registered Person must 19/12/05 ensure that the registered manager is competent, qualified and experienced to run the home and meet its stated purpose, aims and objectives. This is with regard to obtaining a qualification in level 4 NVQ in both management and care. (This is a repeat requirement. DS0000017723.V262882.R01.S.doc Version 5.0 Page 22 4. YA37 17 Woodrows Lane 5. YA39 24 Timescale of 27/06/05 not met. ) The Registered Person must 19/12/05 ensure that there is an effective quality assurance and quality monitoring systems in place to measure success in achieving the aims, objectives and statement of purpose of the home. (This is a repeat requirement. Previous timescale of 01/12/04 not met.) The Registered Provider must 30/12/05 ensure that they conduct a visit and supply a copy of the visit report in accordance with Regulation 26. (This is a repeat requirement. Timescale of 27/06/05 not met.) The Registered Manager must 19/12/05 ensure that the health, safety and welfare of service users is safeguarded through the completion of appropriate safety certification. (This is a repeat requirement. Previous timescale of 01/12/04 not met.) 6. YA41 26 7. YA42 23 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 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Woodrows Lane DS0000017723.V262882.R01.S.doc Version 5.0 Page 24 - 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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