Inspection on 27/09/07 for 17 Woodrows Lane

This inspection was carried out on 27th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 1 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 17/10/06

17 Woodrows Lane 01/11/05

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 Sarah Hannington Unannounced Inspection 27th September 2007 11:00 17 Woodrows Lane DS0000017723.V348091.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 Woodrows Lane DS0000017723.V348091.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 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.V348091.R01.S.doc Version 5.2 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 Miss April Phillips 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.V348091.R01.S.doc Version 5.2 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) 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 The total number of service users accommodated must not exceed 6 persons 17th October 2006 Date of last inspection Brief Description of the Service: 17 Woodrow’s 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.V348091.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and covered all of the ‘Key Standards’ as well as any requirements from the last site inspection. The manager was present throughout the inspection and the site visit took four hours to complete. Another four hours were used looking through various pieces of information before the site visit. Prior to this inspection CSCI (Commission for Social Care Inspection) sent out surveys to all interested parties and the home was sent a (AQAA) Annual Quality Assurance Assessment form by CSCI (Commission for Social Care Inspection) that asked the manager how well the home is meeting the needs of the people that live at Woodrows Lane, how they are suporting the staff and generally an overall assessment of the home itself. Additionally we looked at what else we already knew about Woodrows Lane. Information collated and gathered by CSCI, from surveys returned by residents, relatives and staff, AQAA and discussion during the site inspection will be reflected, used and quoted within this report. What the service does well: The manager and her staff came across as friendly, knowledgeable, and experienced. Residents enjoy a wide range of activities both in the home and the local community. The home is clean and fresh, well maintained and provides a comfortable, homely environment. All surveys returned were complimentary to the home, staff and care received. The AQAA was filled out appropriately and gave a good clear picture of the home. Information written in the AQAA was evidenced through out the site inspection in various pieces of documentation looked at. The AQAA proved to be an accurate, reflective and a good self-assessment. Documentation on the site premises was easily found, of good quality and had clear information. Feedback from relatives and service users show they have confidence in the management and staff. One relative states in a survey; ‘ I am totally satisfied with the care my relative receives. The staff are very caring and take their responsibilities seriously. Also they are good fun!’ 17 Woodrows Lane DS0000017723.V348091.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. The summary of this inspection report can be made available in other formats on request. 17 Woodrows Lane DS0000017723.V348091.R01.S.doc Version 5.2 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.V348091.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5. (Adults 18-65) 3 and 6 (older people) Quality in this outcome is is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives are given a service user guide which informs them of the services provided and they also are encouraged to visit the home prior to any admission, which allows prospective residents and their families to make an informed choice as to whether or not the home will met their needs. EVIDENCE: The admission process/policy has been reviewed and changed and now includes the procedure for admissions and introductory visits. Policies and procedures are in place regarding pre-admission activity such as a prospective resident visiting the home and assessments to be carried out prior to them moving in. There are no vacancies at present as all residents have been in place for a number of years. 17 Woodrows Lane DS0000017723.V348091.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. (Adults 18-65) 7,14 and 33 (older people) Quality in this outcome is is good. This judgement has been made using available evidence including a visit to this service. Care Plans reflect and highlight all residents’ individuals’ needs. EVIDENCE: The home could evidence that service users had been consulted with regarding assessments and changing needs. The care plans did acknowledge service users personal goals. Evidenced was involvement of medical professionals and local PCT teams. Care plans highlighted individual health needs and evidenced that residents are professionally assessed and offered services that catered for their ‘specific’ needs. Healthcare needs of residents are met and appropriate professionals are consulted when required i.e. Occupational Therapist, District Nurse Services, Community Psychiatric Nurse Services, GP, Dentist, Opticians 17 Woodrows Lane DS0000017723.V348091.R01.S.doc Version 5.2 Page 10 and behavioural therapists. The home operates a key worker system and staff spoken with were able to demonstrate a good understanding of residents needs. Through discussion with the manager and through looking at individuals’ risk assessments it is apparent that the home has a good risk assessment procedure in place which explores why some risk taking is a positive thing, as well as being balanced enough to prevent high risk situations developing. These documents have recently been reviewed to enable key workers to undertake this task. 17 Woodrows Lane DS0000017723.V348091.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. (Adults 18-65) 10,12,13 and 15 (older people) Quality in this outcome is is good. This judgement has been made using available evidence including a visit to this service. Activities and use of the community are good and varied. Activities in general, community based leisure pursuits and educational needs are supported and reflective of individual choice. 17 Woodrows Lane DS0000017723.V348091.R01.S.doc Version 5.2 Page 12 A variety of regular nutritious meals are being provided. EVIDENCE: All residents have the opportunity to take part in peer, age related activities and be part of the local community. One resident spoken with informed me that he had been part of an advocacy group and feels that the staff within the home do consult with him regarding the choice of daily activity, food, meals and also about the lifestyle he chooses. When speaking with staff on duty, they showed good awareness of the needs of the residents and gave clear examples of how they would support them to develop their skills in general and promote their independent living skills. Two residents are supported to vote. Residents have regular meetings and annually complete the homes quality assurance survey so that the home can improve upon the service it provides to the individual and residents group. The food in the home is of good quality and menus are reflective of resident’s choice. There are plans to review the current menus and the manager hopes to get a dietician involved for general advice around nutrition. Residents are involved in the food shopping for the home. On the day of inspection it was evidenced that residents, although they may have limited skills in preparing the bigger main meals, are encouraged to partake in the preparation and cooking of smaller snacks. Residents are encouraged to visit and keep contact with relatives. Residents have access to a phone and receive their own mail. There are no restrictions on relatives or friends of the residents visiting. 17 Woodrows Lane DS0000017723.V348091.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. (Adults 18-65) 8,9 and 10 (older people) Quality in this outcome is is good. This judgement has been made using available evidence including a visit to this service. Care Plans reflect and highlight all aspects of an individuals needs. The review of clients care plans is evident. A high standard of medication processes are in place. EVIDENCE: Since the last inspection the manager has ensured that basic knowledge of how medicines are used, how to recognise and deal with problems in use has been addressed amongst staff that administers medication. New procedures and staff checks on medication have been put into place. On inspection medication was stored and recorded appropriately. Staff spoken with about medication gave clear understanding of their responsibilities and of the procedures in use. A Monitored medication dosage system is in place for most residents. Medication is stored in a lockable cabinet and the administration 17 Woodrows Lane DS0000017723.V348091.R01.S.doc Version 5.2 Page 14 records were being maintained in accordance with agreed procedures. One resident administers medication and has the appropriate storage facilities available in their room and was monitored by staff appropriately. Record sheets had been correctly recorded and signed for. Regular management checks of medication are carried out. All aspects of the resident’s health care is included in the care plans. Specialist services are provided if needed for an individual and to give staff guidance. There was evidence of regular health checks and reviews when needed. Personal aids and equipment are available and well maintained. Staff spoken to on the day of inspection had a clear idea of what is required by them whilst giving personal care and evidenced that each resident is treated as an individual. Staff also evidenced when spoken with to respect residents when carrying out personal care needs and keeping their dignity and ensuring privacy. The manager has also developed accredited core training for all staff. 17 Woodrows Lane DS0000017723.V348091.R01.S.doc Version 5.2 Page 15 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 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. (Adults 18-65) 16,18 and 35 (older people) Quality in this outcome is is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure and each service users and relative has a service users guide that highlights the complaints procedure. The homes policy and procedures and training of staff protect residents from abuse. EVIDENCE: Since the last inspection a new complaints procedure has been introduced. The complaints procedure is displayed on a communal information board and all relatives have been sent a copy. There is also a copy of the complaints procedure in a format of the resident’s choice. Since the last inspection there have been no complaints. The manager and all staff are available when relatives visit and if they need to raise any concerns or sensitive issues privately they can do so. Residents spoken with on the day of inspection were complimentary about the care provided within the home and felt all staff are approachable and stated that they would feel confident in making a complaint if need be. Residents meeting are also used as a format for raising any concerns. Staff spoken with regarding the safeguarding of adults evidenced to me that they knew the correct response and procedures to follow. There is further training in safeguarding planned for all staff. 17 Woodrows Lane DS0000017723.V348091.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. (Adults 18-65) 19 and 26 (older people) Quality in this outcome is is good. This judgement has been made using available evidence including a visit to this service. The outside environment is pleasant, attractive and provides appropriate and practical usage for the residents of home. The home environment provides a clean, comfortable and safe environment in which to live in. The home and layout needs to be developed for the specific client group at the home. EVIDENCE: Overall the home environment present no health and safety issues, the environment was homely comfortable, odour free and practical for the use of residents at Woodrow’s lane. 17 Woodrows Lane DS0000017723.V348091.R01.S.doc Version 5.2 Page 17 However some communal areas such as the hallway and stairs could have new carpets, re-painted woodwork and redecoration of walls. One downstairs bedroom needs completion of decoration. The garden has been developed and provides a pleasant area for residents to use. Since the last inspection the manager has put into place a book which record all details of hot water temperatures of wash hand basins and baths. New fire safety assessments have been implemented. Staff have received health and safety and infection control training. 17 Woodrows Lane DS0000017723.V348091.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. (Adults 18-65) 27,28,29 and 30 (older people) Quality in this outcome is is good. This judgement has been made using available evidence including a visit to this service. The number of staff on duty, their experience and skill, are able to meet the needs of residents. Recruitment records are in place and to a good standard. EVIDENCE: Overall the majority of the staff team have been in post for a number of years. Since the last inspection staff training overall has improved. The manager has put into place a new staff training and development programme, which meets Sector Skills Council workforce training targets. Staff also received challenging behaviour and ‘verbal intervention techniques’ training. Staffing levels at Woodrows Lane remain appropriate for the numbers of residents and have the 17 Woodrows Lane DS0000017723.V348091.R01.S.doc Version 5.2 Page 19 necessary skills and experience required to meet the needs of existing residents. Staff meetings and supervision are regular. There is a good recruitment and selection policy in place and contained all necessary checks required. All staff had enhanced CRB checks. 50 of the homes staff are NVQ trained and the manager is currently arranging to study for the Registered Managers Award 17 Woodrows Lane DS0000017723.V348091.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41 and 42. (Adults 18-65) 31,33,35 and 38 (older people) Quality in this outcome is is good. This judgement has been made using available evidence including a visit to this service. Management systems are good and the home is run in the best interests of residents. Evidence to show that teamwork has developed the service and 17 Woodrows Lane DS0000017723.V348091.R01.S.doc Version 5.2 Page 21 improved the standards of care is in place. The management does respond robustly & rectify matters of health & safety when identified. EVIDENCE: Residents and staff are benefiting from a strong management team and the level of service is good. The manager is currently studying for the Registered Managers Award. Quality Assurance is carried out with all interested parties and the information collated will be forwarded to the CSCI and made available to all interested parties. The managers health and safety checks inspected were up to date. However, the Registered Provider does not conduct monthly visits under Regulation 26 of the Care Homes Regulations 2001 Overall the health, safety and welfare of resident’s and staff are protected. 17 Woodrows Lane DS0000017723.V348091.R01.S.doc Version 5.2 Page 22 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 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 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 Standard No Score 37 3 38 X 39 3 40 X 41 1 42 3 43 X 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 17 Woodrows Lane Score 3 3 3 X DS0000017723.V348091.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 YA41 Regulation 26 Requirement The Registered Provider must ensure that they conduct a visit and write a report in accordance with Regulation 26. (This is a repeat requirement. Timescale of 27/06/05, 30/12/05 and 11/12/06 not met.) Timescale for action 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA24 Good Practice Recommendations The registered person should ensure that the internal environment is kept in good repair. This is in relation to the hallway and one resident downstairs bedroom in need of redecoration. 17 Woodrows Lane DS0000017723.V348091.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. 17 Woodrows Lane DS0000017723.V348091.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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