Inspection on 20/02/07 for 1a Daubeney Gate

This inspection was carried out on 20th February 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1a Daubeney Gate 27/01/06

1a Daubeney Gate 29/12/05

1a Daubeney Gate 11/01/05

1a Daubeney Gate 10/06/04

1a Daubeney Gate 19/02/04

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

CARE HOME ADULTS 18-65 Daubeney Gate (1a) Shenley Church End Milton Keynes Bucks MK5 6EH Lead Inspector Barbara Mulligan Unannounced Inspection 20th February 2007 10:00 DS0000015054.V325501.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 DS0000015054.V325501.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. DS0000015054.V325501.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Daubeney Gate (1a) Address Shenley Church End Milton Keynes Bucks MK5 6EH 01908 505245 01908 505246 mail@macintyre-care.org www.macintyrecharity.org MacIntyre Care 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) Mrs Sally Charrington Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000015054.V325501.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th January 2006 Brief Description of the Service: 1A Daubeney Gate is a purpose built care home for adults with learning disabilities located in a residential part of Shenley Church End, Milton Keynes. The home is close to local shops and is a short drive from the city centre and public transport networks are close to the home. The property is owned and staffed by MacIntyre Care Services. Each service user has a single bedroom and these are decorated and arranged to reflect different interests and tastes. The home has a good size lounge with patio doors leading to a large enclosed garden. There is a separate dining room next to the kitchen and laundry and staff sleeping in and office facilities on the ground floor. The home has ample toilet and bathroom facilities. Service users have a cat called Jessie. Service users of both sexes were being cared for at the time of the inspection, with a range of personal care needs. Fees range from £24,401.52 per annum to £ 44,110.04. . Items such as toiletries, trips out and sundries would be additional charges to service users. DS0000015054.V325501.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was undertaken on Tuesday 20th February 2007 at 10am. The visit consisted of discussions with the senior support worker, care staff and service users. A tour of the premises and an examination of the homes records, policies and procedures was undertaken. The inspection officer was Barbara Mulligan. The senior support worker who assisted with the inspection is Hugh Findlay. Twenty-seven of the National Minimum Standards were assessed during this visit. Twenty-four of these are fully met, and three almost met. As a result of the inspection the home has received four requirements. No comment cards were received from service users, relatives and/or representatives. The evidence seen and documentation observed indicates that this service meets the diverse needs [e.g. religious, racial, cultural, disability] of individuals within the limits of its Statement of Purpose. The inspector would like to thank the senior support worker, the staff team and service users for their cooperation and assistance during this inspection. What the service does well: The home is a nice and comfortable place to live. There is a good and assessment process in place to make sure the home can meet the needs of the people who live there. DS0000015054.V325501.R01.S.doc Version 5.2 Page 6 The care plans tell the staff how to care for the people living in the home. The people who live in the home are good friends. The home makes sure that the people who live in the home are safe when they go out and take part in activities. The home provides good healthy meals for all the people who live there. The home looks after the medicines safely, for the people who live there. The home keeps all the important information and photos of all staff. DS0000015054.V325501.R01.S.doc Version 5.2 Page 7 The people who live in the home and their friends and family, are supported to make their views known. What has improved since the last inspection? What they could do better: This inspection at the home has shown 4 things need to be done to make it okay. Staff need to have more training to help protect the people living in the home from harm. DS0000015054.V325501.R01.S.doc Version 5.2 Page 8 Broken bedroom furniture needs to be replaced MacIntyre Care. All staff who work in the home must receive up to date fire training. Fire All staff who work in the home must receive up to date moving and handling training. 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. DS0000015054.V325501.R01.S.doc Version 5.2 Page 9 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 DS0000015054.V325501.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users needs are thoroughly assessed prior to admission, ensuring that staff are prepared for admission and have a clear understanding of the service users requirements. EVIDENCE: No new admissions had taken place since the last inspection, or indeed for some time, so direct evidence of the management of new admissions was not available for scrutiny. However discussion with the senior support worker and observation of procedures confirmed that any new admissions would receive a full assessment by senior staff before consideration of placement and that introductory visits and overnight stays would take place prior to any final placement decisions. The views of existing service users would be taken into account. The assessment tool is called “Moving into Macintyre Care” and is comprehensive and detailed. Pictures are included alongside written information to enable the potential service users to understand the process. DS0000015054.V325501.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear and consistent care planning systems are in place that provides staff with adequate information they need to satisfactorily meet service users needs. Systems are in place to involve service users in decisions about their lives, with assistance and communication support that allows them to influence their lifestyle and how the home is run. Risk assessment documentation is in place ensuring that service users and staff are safe and not at risk of accidents and harm. EVIDENCE: Following the previous inspection a requirement was issued for all person centred planning documentation for care plans to be completed for all service users within 4 months. It is pleasing to see that this has been complied with. Each service user living at the home has an essential lifestyle plan, and there are two of these, one is in a format suitable for the individual service user. There is also a Person Centred Plan which is formulated by the service user and is a reflection of their wishes, goals and aspirations and there is a separate DS0000015054.V325501.R01.S.doc Version 5.2 Page 12 file for health screening information, medical information and medication records. Care plans looked at are detailed and informative and reflect the changing needs of the individual. Care needs are identified with an action plan detailing how staff will meet those needs. Care plans appear to be in line with the service users current identified needs. All information contained on file is of a high standard and aids staff to provide appropriate support. There is good evidence of health screening taking place and how the home supports service users to access health advisors. Staff respect service users rights to make decisions and individuals are provided with assistance and communication support to make decisions about their lives. The inspector was informed that the home will seek information and assistance from relatives and will use advocates if it is requested or felt to be necessary. Service users at 1A Daubeney Gate have monthly house meetings. Minutes are kept of these that demonstrate how individuals are given the opportunity to make informed decisions about their lives and how choices are made. Risk assessments are in place and examples seen include personal care, medical and health support needs, swimming, accessing the community and using transport. All risk assessments were found to be up to date, signed and dated by the author. DS0000015054.V325501.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users can take part in age, peer and culturally appropriate activities, which support and enrich service users social and educational opportunities. Families and friends are welcomed to the individual’s homes with no restrictions unless previously requested by the service user or significant others. Service users rights are respected and the daily routines of the home promote individual choice and providing service users with the ability to be as independent as their needs allow. Service users are supported to develop their own menus and participate in some cooking tasks, which promotes independence and choice while at the same time reinforcing independent living skills. DS0000015054.V325501.R01.S.doc Version 5.2 Page 14 EVIDENCE: Service Users are supported to take part in a variety of activities both in their home and in the local community. One individual who lives at the home has a part time job in the bakery at Great Holm, which is owned and managed by MacIntyre Care. There is good use of community resources with adequate staff support to access these resources. All service users are well supported by the home and Macintyre Care in pursuing appropriate activities. One service user attends a local gym and good use is made of the public transport systems. Service users attend day care service four days a week and have a day off in the week. On the day of the inspection two individuals were attending the cinema on their day off. Staff knocking on bedroom, toilet and bathroom doors maintains the privacy of individuals. If service users are unable to open their mail, staff will open it with the individual and read the contents to them. Preferred term of address are used for service users and this is recorded in the care plans. All care staff seen interacting with service users do so with respect and in a manner that is appropriate to the individual. Service users are supported to maintain contact with their families dependent on their own circumstances and personal wishes. There are no restrictions on visiting times and individuals can entertain family and friends as they wish. Service users choose their own menus and are supported to prepare and cook meals. The main meal is in the evening. Staff support individuals to make healthy choices. Meals are offered three times a day and service users have access to snacks and drinks throughout the day. The dining room is bright and spacious and staff eat meals together with service users. The nutritional needs of service users are assessed and there is evidence of regular monitoring in care plans. Service users are weighed regularly and recorded in care plans. DS0000015054.V325501.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs are outlined within their individual plans, ensuring that the manner in which they are supported and cared for by staff is appropriate and promotes their preferences. Healthcare support for service users is good ensuring service users health and wellbeing is promoted and protected. Medication procedures within the home are robust and staff training is good, which ensures that service users are protected by the systems in place. . EVIDENCE: Information regarding personal care is recorded in the individual care plans. Service users choose when they like to go to bed, have a bath, have their meals and take part in other activities. Care plans set out in detail the service users preferred routines, likes and dislikes and partnerships with families and friends. DS0000015054.V325501.R01.S.doc Version 5.2 Page 16 Staff ensure that personal care is flexible, consistent and responsive to the changing needs of service users. This is well documented in care plans. The staff group is balanced to ensure choice of male, female and age related preferences when delivering personal care. Each service user has their own health care file. This records evidence of regular and thorough healthcare screening. Chiropody Services are accessed by two service users on a regular basis. Additional support is accessed through the Community Learning Disabilities team where service users can access physiotherapists, occupational therapists, speech therapists, and community dietician and continence advisor. The inspector was informed that the dietician has advised the home about diets and nutritional screening appears to be good and this is well recorded in care plans. Visits to the home from healthcare professionals take place in the service users bedrooms. Staff provide support to individuals needing to attend outpatient and other appointments. There is evidence that eye screening is being undertaken on a six monthly basis and an optical service visits the home to carry this out. Dental services are accessed via the hospital and check ups are carried out six monthly. Service users are able to choose their own GP and have access to all NHS healthcare facilities in the local community. None of the service users in the home are able to self-administer their own medication. The home uses a monitored dosage system. Medication records seen are fully completed with no omissions noted. There were no out of date medications held in the service users home with a returns procedure in place. There are no controlled drugs in use at the time of the visit. Training records demonstrate that staff have undertaken accredited training in the safe handling of medicines. DS0000015054.V325501.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Organisation has a robust complaints procedure which is accessible to service users and significant others, enabling them to make a formal complaint appropriately. Policies and procedures to protect service users from abuse are in place, but some care staff have not received up to date POVA training, leaving service users at risk of abuse and harm and their rights to be safe are not protected. EVIDENCE: There is a complaints procedure and this informs the complainant who to approach with their complaint. Copies of the complaints procedure are included in the Statement of Purpose and the Service Users Guide and this gives guidance about referring a complaint to the Commission for Social Care Inspection. The home has received two complaints since October 2006. These have been responded to with in the timescales stated within the complaints procedure. The Commission for Social Care Inspection has not received any complaints about the home. The home use the Milton Keynes Multi Agency “Protecting Vulnerable Adults from Abuse” policy and an organisational policy in conjunction with this. This includes guidelines for staff about the responsibilities of the staff, types and DS0000015054.V325501.R01.S.doc Version 5.2 Page 18 signs of abuse and what to do if you suspect abuse. All care staff receive training about Adult Abuse and this forms part of their induction. However, it is noted that one staff member received this 2003 and two staff in 2004. This needs to be updated and is a requirement of the report. The homes policies regarding service users money and financial affairs ensure service users access to their money, valuables and safe storage is safe guarded. There is a gifts procedure that provides staff with guidelines about receiving personal gifts from service users. DS0000015054.V325501.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is good, providing service users with an attractive and homely place to live. The overall quality of the furnishings and fittings is good ensuring the safety and comfort of service users. Standards of cleanliness at the home appear to be good meaning that service users live in an environment that is clean and hygienic, protecting their health, safety and welfare. EVIDENCE: 1a Daubeney Gate is a residential home providing care and support to adults with a learning disability. The home is located in a residential area of Milton Keynes. It is close to local shops and is on a bus route to Milton Keynes where a wider range of activities and amenities are available. DS0000015054.V325501.R01.S.doc Version 5.2 Page 20 The home consists of a two-storey building. All of the bedrooms are single and are all lockable. Service users can choose to use this facility. There is one communal lounge. This is nicely decorated, bright and homely. There are many personal touches around the home for example, plants, pictures and photos. The kitchen was newly fitted three months ago. This is clean, spacious and well looked after. This is accessible to all service users. The furnishings observed in communal areas are of good quality and suitable for the range of interests and activities preferred by service users. Lighting in communal areas is domestic in character and sufficient to facilitate reading and other activities. The home has a pleasant garden that is maintained by staff and service users. There are no CCTV cameras in use within the home at the time of the inspection. There are accessible toilets available for service users throughout the home. The inspector was invited by service users at the home on the day of the inspection to view their individual bedrooms. Some rooms have broken or inappropriate bedroom furniture. This needs to be replaced by the organisation and will be a requirement of the report. Laundry facilities are sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten and do not intrude on service users. The home has an infection control policy and the inspector observed this. Instructions are in place for the washing of soiled linen. There are no outstanding maintenance issues found on the day of inspection that would affect the health and welfare of the service users. DS0000015054.V325501.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a staff team who are appropriately trained to ensure that service users are cared for by skilled staff at all times. However all staff need to undertake Makaton training to ensure there are staff on duty at all times who can communicate with the service user in their chosen sign language. There are effective recruitment procedures in place to ensure service users are protected from harm. There is a staff training and development programme which ensures staff fulfil the aims of the home and meet the changing needs of service users. EVIDENCE: Staff are aware of the organisations policies and procedures and understand how their work, and that of other staff, promotes the main aims of the home. There is written evidence that is achieved through staff meetings, and formal staff supervision sessions. DS0000015054.V325501.R01.S.doc Version 5.2 Page 22 There is one service user who uses Makaton sign language to communicate. Training records show that seven staff have received basic training in Makaton and it strongly recommended that the remaining staff members receive this training to ensure there are staff on duty at all times who can communicate with the service user in their chosen sign language. There were no staff members under the age of eighteen and there are no staff under the age of twenty one left in charge of the home at any time. At the time of the inspection there is one staff member with NVQ level 3 training and the manager has completed NVQ level 4. The inspector was informed that five staff are currently undertaking NVQ training. The inspector requested to look at the recruitment files for staff including the most newly appointed staff. Four files were examined. All staff files looked at contains two references, copies of driving licence, certificates of training and a health check. There is evidence that staff have had a criminal records bureau check before they commence work and all staff are checked against the POVA register. Staff spoken to confirmed the process of recruitment. There is an induction programme in place to ensure that new staff members are familiarised with the organisation and their roles and responsibilities and provides the staff member with a personal development portfolio. This includes fire safety, moving and handling techniques and core skills training. Training records reflect that staff have received mandatory training although these now need to be updated. This has been made a requirement under standard 42. There is specialist training available for staff, an example of this is Autism training and Epilepsy training. Staff confirmed that there are regular staff meetings. DS0000015054.V325501.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is supported well by the staff team in providing clear leadership and demonstrating an awareness of their roles and responsibilities to the benefit of the service users. Various methods of measuring quality assurance are in place ensuring that the quality standards that apply to service provision are maintained to a prescribed standard and, in relation to service users requirements, are not compromised. There are systems within the home that are used to ensure that service users health, safety and welfare are protected and promoted. EVIDENCE: The present registered manager was unavailable during this inspection. However, staff stated that the registered manager is open and transparent. DS0000015054.V325501.R01.S.doc Version 5.2 Page 24 Evidence was seen of training undertaken by the manager and this includes Autism training, medication training and Infection control training. The registered manager appears to be well supported by the staff team and staff supervision and team meetings occur regularly. The registered manager has completed the Registered Managers Award. The home has a complaints procedure in place and a whistle blowing policy, which enable staff and service users to voice concerns and affect the way in which the service is delivered. The organisation undertakes monthly Reg 26 reports and these were available for inspection. The senior support worker said that service satisfaction questionnaires have recently been sent out to service users. These are in the process of being completed but were not available for inspection. The senior support worker was unsure how the organisation used the feedback gained from these questionnaires. The inspector requests a copy of the outcome of the recent Quality Assurance audit. Weekly service users meetings take place and records are kept of these. Records were seen for fire safety. Following the previous inspection a requirement was issued for all new staff to receive fire awareness training within 6-8 weeks of employment in line with the health and safety training provided during the induction process for the organisation. Although this appears to have been complied with it was noted that three care staff have not received fire training since June 2004 and a further three staff in 2005. This must be up to date for all existing care staff and will be a requirement of the report. Fire records are comprehensive and up to date. The most recent fire drill was undertaken on 18/01/06 and there is an up to date fire risk assessment. Some mandatory health and Safety training for care staff needs to be updated. Training records demonstrate that two staff do not appear top have received Manual Handling training and three staff have not received this training since 2004. This needs to be updated and will be a requirement of the report. Service reports are in place for PAT testing dated 16/09/04, gas boiler certificate is dated 30/11/05, electrical installation certificate is dated 04/03/03. There is evidence of monthly health and safety checks. COSHH sheets are up to date and accurate. The inspector looked at Infection Control guidelines that are available for all staff. DS0000015054.V325501.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 x DS0000015054.V325501.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 13 (6) Requirement The registered manager is required to ensure that where necessary POVA training is updated for care staff. The registered provider is required to provide appropriate bedroom furniture to replace existing broken or inappropriate bedroom fixtures. The registered manager is required to ensure that all care staff receive up to date fire training. The registered manager is required to ensure that all care staff receive up to date Manual Handling training. Timescale for action 30/05/07 2 YA26 23(2) 30/06/07 3. YA42 23 (4) 30/05/07 4 YA42 13 (5) 30/06/07 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 YA32 Good Practice Recommendations It is strongly recommended that all care staff receive DS0000015054.V325501.R01.S.doc Version 5.2 Page 27 Makaton Training. DS0000015054.V325501.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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