Inspection on 23/02/07 for 2 Cowley Way

This inspection was carried out on 23rd February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

2 Cowley Way 07/12/05

2 Cowley Way 29/06/05

2 Cowley Way 15/02/05

2 Cowley Way 08/09/04

2 Cowley Way 01/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 2 Cowley Way, Bentilee Stoke-on-trent Staffordshire ST2 0RB Lead Inspector Berwyn Babb Key Unannounced Inspection 23 February 2007 14:30 2 Cowley Way, DS0000008213.V330863.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 2 Cowley Way, DS0000008213.V330863.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. 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 2 Cowley Way, Address Bentilee Stoke-on-trent Staffordshire ST2 0RB 01782 596047 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) cowleyway@choicesha Choices Housing Association Limited Mrs Andrea Abbotts Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (2) of places 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: 2 Cowley Way is a detached purpose built domestic style property that is registered to provide 24-hour care for up to eight adults with a learning disability, two of whom may be over retirement age. The home provides accommodation on two floors, each for four gentlemen currently. The ground floor of the home comprises a lounge/diner, domestic kitchen, laundry, four single bedrooms each with a wash-basin, a shower room/WC and an assisted bathroom/WC. It has been designed throughout this level to meet the needs of people with a physical disability. The first floor is a replica of the ground floor, save for the absence of a laundry and there is a standard bathroom/WC. Grab rails have been fitted throughout the home as required. There is a small private garden and off road parking. The design and location of the building fit in well with the other surrounding properties. The home is on the edge of a large housing estate and there is good access to shops and a local supermarket. There is easy access to the main bus route to Hanley and Longton town centres. 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The this key unannounced inspection was carried out during the afternoon or Friday the 23rd of February 2007, and at the outset the home was found to be staffed by carers from another nearby home belonging to the same providers, and which has good links with this home, hosting social events and exchanging resident visits, with the gentleman of 2 Cowley Way. The designated staff of the home were attending a meeting at the headquarters of the provider, and on being informed that an inspection was taking place, the Registered Care Manager returned to provide helpful assistance and hospitality for the rest of the afternoon. All the gentlemen were in the home for the majority of the time, but their daily schedule was not interrupted, and two of them benefited from the input of one of the carers to escort them (one needed someone to push his wheelchair) to the nearby newsagent, to pay the paper bill, and pick up a copy of a favourite periodical. All spoke with the inspector, and three interacted to a greater degree than the others, displaying their personal space, and enabling their opinions to be recorded. Assistance of the manager and carers was sometimes necessary to clarify exactly what it was they wanted to say, but nobody appeared to be upset by this, and all engaged very positively with the inspection process. Discussion revealed ongoing tension between two of the residents, and the various measures that were being taken to resolve this, and the inspector was able to observe examples of de-escalation techniques being used, and discuss the situation with one of the residents who displayed considerable understanding and sensitivity to the behaviour of his colleague, and was mature and responsible about the whole thing. As well as interacting with the gentlemen and care manager and staff, the inspector reviewed various documents in the home, including risk assessments and Personal Care Profiles, and made an extensive tour of the communal areas of the home, and of three bedrooms, and the exterior of the property. The current scale of charges for accommodation was given as ranging from £463 per week to £470 per week. What the service does well: 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 6 This home continues to provide comfortable domestically styled accommodation for eight persons (currently all men) whose primary diagnosis is Learning Disability, with well trained and motivated staff employed to help them maximise their potential for living in a local community. 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. 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. The quality in this outcome area for this group of residents was good. This judgement has been made using available evidence including a visit to this service. New residents had only been admitted on the basis of a full assessment undertaken by people competent to do so, and involving the prospective resident, and using and appropriate communication method, and (where appropriate) using an independent advocate. EVIDENCE: There had been no admissions to this home for the last four years. Discussion took place with the Registered Care Manager about the referral process, and she confirmed that all residents currently in the home had moved from longterm provision provided either by the Health Authority, or by the Local Authority, and therefore, had benefited from full multi agency assessments prior to their initial contact with the home. She went on to point out that because of the length of time some people had been in residence, the format of these assessments would be different to that being used under current legislation. 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 9 The file of one of the residents was reviewed in detail in this area, and it contained all the information that is required under current procedures, and had been supplemented by an excellent review, six weeks after that resident had come to live in the home. 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. The quality in this outcome area for this group of residents was good. This judgement has been made using available evidence including a visit to this service. The known and changing needs and personal goals of the residents had been assessed, and they were being encouraged to make decisions where ever they were able, and to take acceptable risks. EVIDENCE: The Personal Care Profiles of four residents were reviewed, and these demonstrated that there was a fully developed care plans (including appropriate risk assessments) for each of these residents, based on a full assessment of their needs and choices, and reviewed at least in the minimum intervals recommended, and more often as and when necessary. 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 11 Discussion with the Registered Care Manager detailed how even when risks being taken by a resident were unsafe or unacceptable, monitoring, diversion, and training, had been focused on enabling that person to continue in a modified and less contentious manner, rather than disabling them by Draconian restrictions. The inspector was able to observe residents taking decisions about how they wanted to spend their time, and being supported to do this by the input of staff where this was necessary During the afternoon one resident decided that he would like to go to the local newsagent to pick up his copy of a sporting periodical, and to pay his weekly paper bill, and another resident took the opportunity to go with him and see if there was anything that he would like to buy. Arrangements were quickly made for a member of staff to be released to push the wheelchair of the gentleman not able to walk that distance, and when the little group returned, the two men were in high spirits, and had obviously enjoyed being able to exercise their choice to go into the community and engage in everyday activities. 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, and 17. The quality in this outcome area for this group of residents was good. This judgement has been made using available evidence including a visit to this service. Residents who were able to, enjoyed going to college or other appropriate day provision, and all were accessing the community to have a presence there, maintaining friendship links that they had set up over many years, being treated with dignity and having their privacy respected, and receiving nutritious, appropriate, and appealing meals. EVIDENCE: When the inspector arrived at the home one of the gentleman was absent and engaging in adult training at a nearby provision, and when he returned from this he indicated that he had very much enjoyed himself. None of the current residents of this home would be suitable for or benefit from paid employment, and two have passed retiring age. 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 13 During the tour of inspection, two other residents were extremely please to be able to show records of achievement from various establishments, both educational and vocational, and it was obvious that attaining these had contributed to an improvement in their feelings of self-worth. In discussing a recommendation from a previous report, it was established that one gentleman who did not like going on formal holidays, had enjoyed a program of visiting agricultural shows and farmers markets in accordance with a particular interest of his, and he was particularly enthusiastic about the overnight stay that he had experienced on a nearby Working farm. Another resident who used to enjoy independent holidays had found these impossible due to limited mobility, and reduced confidence that came with it, and had been assisted to join two of his fellows and two members of staff for three shorter holidays which included attending Race Meetings to which he was particularly attracted. Documentation showed that with his agreement, his personal carer had been changed, and he was no assisted by somebody who shared his overriding interest in horses. Record showed that various visits were made (usually low key, with only one or two residents and a personal carer) to eating houses and places of entertainment, as well as trips to the shops and inter-house links with other similar establishments managed by the same provider. It was established that most of the current residents had known people in other Choices houses for many years, sharing a common background in health or local authority institutions, and in addition to more general visits for such things as coffee mornings and parties, individual swapped visits among the home is with people with whom they were particularly friendly. Some residents still had family, and were keeping in touch with them. (One gentleman was able to display the mobile phone that he possesses.) Staff were observed and overheard to be solicitous to the privacy and dignity needs of residents, and to be sensitive in the areas of guidance where personal hygiene was involved. They were observed both directly and through examination of the care records to be engaged in assisting the man to take responsibility for their own dignity, especially where some of their spontaneous actions may otherwise have made them a target for ridicule. As the afternoon progressed, preparations were on hand for the evening meal, and residents were variously offering advice or practical assistance with this task and indicated that they were enjoying the process. Records of food provided showed appropriately varied menus, and reference to the health components of care plans showed where professional advice had been received and acted upon in order to meet specific dietary requirements, or to decrease or maintain body weight. 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, and 21. The quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Systems were in place to manage medication, to give residents access to appropriate health professionals, and to support them and a flexible and dignified way. The subject of death and dying had been approached to establish people s wishes. EVIDENCE: Whilst checking medication administration records, the inspector noticed a small number of gaps in relation to one resident. Further examination determined that medication had not been given at these times and the reason had been entered in the legend at the bottom of the sheet under the heading other . These notes had been both signed and dated, and therefore no requirement is going to be made in relation to this omission from the MAR sheet, but the care manager was informed that a signature or symbol must be inserted into each space provided on the sheet for recording where a 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 15 medication had been administered, refused, or for any other reason not to given. All other aspects of the methods of storing and administering medication were found to be satisfactory, and schedules were made available to confirm where each member of staff had received the appropriate training. Discussion took place with one resident over the daily task of shaving, and he confirmed that he was supported and enabled to do this for himself, and that he was equally satisfied with other steps taken by staff to assist him with his personal care. Reference to the Personal Care Profiles established that annual health checks were being carried out, and that residents were being assisted to make and keep appropriate appointments with a whole range of healthcare professionals including; consultants, GPs, nurses, chiropodists, dentists, opticians, and those concerned with detecting and remedying, hearing loss. In addition to this, there was evidence that were a particular need had been identified with an individual, for example someone who had started displaying wandering behaviour during the night, appropriate advice and referrals had included blood tests, medication review, CT scan, enhanced monitoring, and greater input from the GP. During the afternoon one gentleman was involved in discussion with the manager about a medical aid that have become particularly uncomfortable for him, and she made a note to speak to the doctor to see what steps can be taken to make it more comfortable. During the examination of care plans it was noted variously that some people had established their wishes at the end of their life, and the others preferred not to consider or discuss this, and to leave it to the discretion of those charged with their care, or as directed by their families. 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were being protected by the policies and procedures practised in the home. EVIDENCE: Management of the home were in the process of making the complaints procedure, in line with all other documentation, more accessible to the residents of the home by the use of pictures. They had discarded the notion of using a computer generated images in favour of pictures taken with a digital camera of everyday objects that were familiar to the residents and thus more likely to convey the information being provided for their protection. The inspector and Registered Care Manager discussed a complaint that had been received by the home, but which had been dealt with effectively and in the appropriate time scales, and the procedures that had been followed had displayed the best practice expected of people engaged in the protection of Vulnerable Adults. Education and training had been made available to a resident so that he could be enabled to participate in an activity of his choice, rather than being disabled by being restricted from enjoying this activity. Appropriate steps were seen to have been taken with all agencies and interested parties, in line with the policy agreed locally, and subscribed to by the providers. 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 17 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 18 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, 27, 28, and 30. The quality in this outcome area for this group of residents was good. This judgement has been made using available evidence including a visit to this service. The home was suitable for its stated purpose, rooms were of a generous size and well fitted, there were adequate bathroom and toilet facilities and generous provision of shared space, with satisfactory management of hygiene, infection, and odour control. EVIDENCE: A cursory visual examination was made of the exterior of the property and brickwork, window surrounds, doors, roof, and rainwater furniture all appeared to be in good order, and there was adequate car parking in well maintained areas, and well maintained shrubbery and enclosed lawn to the frontage of the Property. At the rear was a garden area and further protected parking accessed through head high double gates, and comprising of a patio area for the use of Sun loungers and other garden furniture during good weather. 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 19 (This was being stored both in the laundry and in a vandal proof resin shed for the winter) There were also pathways decorated with planters, a lawn, and vegetable area, and a small greenhouse. The construction of the home blends in with the surrounding areas, and does not stigmatise it as being a care institution. Appropriate bins were provided for different categories of waste, and these were neatly and securely located and did not detract from the surroundings. Internally the home was clean and warm and well maintained with no obvious need for redecoration, but the care manager was able to refer to an ongoing programme of maintenance and upgrading. A sample all the rooms visited were adequately sized and comfortably furnished, and the resident had a Yale type key with which to keep it locked. The resident stated that the bed was comfortable and that he enjoyed watching his television in the privacy of his own room and that the vanity basin was suitable for his purpose, and that he knew how to operate the emergency call system. In addition to the main light he has one accessible from his bedside, and the decoration was pleasing and well maintained. He had been able to display a large picture of his favourite football Stadium. (In response to questioning he stated that he would like to go and see his team play, but was not doing so, though when this was taken up with the care manager it was learned that he used to be a regular supporter, but had ceased doing this at his own request. She did however agree to revisit this interest of his, especially as one of the bank staff covering the home at this time knew of a member of staff in the home where she normally worked, who took one of their residents to see this local club, and would possibly be able to take this resident as well). His radiator had the appropriate safety cover to protect him from accidental burns. (All radiators and hot water pipes in high priority areas of this home were appropriately covered, though some of those in the communal aerials such as passages remain unprotected.) Toilets and bathrooms had appropriate privacy locks that were fitted with equipment to make them easy-to-use by anyone with dexterity problems, as well as being appropriately furnished including grab rails and support bars to aid mobility. There was a lounge/diner and domestic kitchen on each of the floors, and in addition there was a laundry on the ground floor. The communal areas were well maintained and comfortably furnished. 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 20 The laundry had a sealed type of floor, easy wipe walls, and washing facilities, a washer and a drier, and an ironing board, storage for garden chairs, there were Red bags available for use in case of any contaminated bedding. There was also equipment to do the ironing, and the south-facing windowsill was being utilised to force seedlings ready for the vegetable garden. The whole area was extremely clean and tidily set out, and nothing was seen during the tour of the home are to compromise infection control or hygiene standards. 2 Cowley Way, DS0000008213.V330863.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, on 35. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Residents were seen to be supported by competent and qualified staff who had been appropriately recruited to ensure their protection and trained to meet their needs. EVIDENCE: During this inspection one persons personal records was sampled to determine how their training needs had been met, as was the general matrix of training received and scheduled that the care manager keeps as an aide memoir to ensure that mandatory, induction, and refresher training, is arranged and undertaken at the appropriate times. The member of staff chosen at random had undertaken mandatory training in fire safety, emergency first aid, personal safety, moving and handling, the management of actual and potential aggression, and food and hygiene, and during her induction and on periodic refreshers had undertaken such courses as; 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 22 What is a learning disability? Keeping records. Interpersonal communication. Abuse. Personal care profiling. Sexuality. The storage and Administration of medication. Lone working, and training on the origins and determinants of behaviour. Currently there are no staff vacancies in this home, and except in an extreme emergency (such as the need to take someone to hospital) when one person may be on duty for no longer than one hour on their own, there are two members of staff on duty at all times during the waking hours, and one person sleeping in at night. Since the last inspection two staff have left the home, one to be a family carer and one to transfer to night duty at another home run by the same providers. They have been replaced by, somebody who had previously worked at this home, and by a developmental post that introduces a former staff nurse to the team. Rotas for the next two weeks showed an extra shift one day from the 11 oclock until seven oclock to provide enough help from the preparations of a birthday party for one of the residents. 2 Cowley Way, DS0000008213.V330863.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, on 42. The quality outcome for this group of residents was good. This judgment was made using all the available evidence including that gathered during a visit to the service. The manager was competent in all she did, and ran the home following the best principles of current thinking in good practice for people with Learning Disabilities. Records showed maintenance of the home to be appropriately undertaken, and measures aimed at maximising the health and safety of all those in the home had been completed. EVIDENCE: Probably the most significant evidence in this section was a letter dated 09/01/07 from the Fire Protection Officer stating that all issues raised in his previous letter of 21st of March 2006 had now been addressed. 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 24 There was further evidence of two yearly input of outside training by a Department of the Fire service, six monthly evacuations, use of training questionnaire, inclusion of fire training in all quarterly staff meetings, the commissioning of a new fire detection system in June of 2006, including the replacement of the Fire information panel that had been giving concerned for some time. The current care manager is both qualified, competent, and experienced to carry out her role, and was able to point to recent academic research to maintain her level of contemporary best practice (in this instance into Aspergers syndrome) as well as receiving input from consultant psychiatrists, and enrolling on courses at the nearby hospital. A more dynamic approach to gathering information about what people felt about the quality of the service had been suggested in the last report, and a sample of responses to the ensuing initiative that followed the suggestion included comments such as: it would be very difficult to raise this standard (of care) . The staff are first class in everything and very caring . I have peace of mind knowing (name of the resident) is being well cared for Staff are very helpful to her. Nothing is too much trouble for them . I find that staff go out of their way to be helpful . They are all very kind to my son . Additionally CSCI continues to receive the report of the monthly monitoring visits to the principal officers of the providers make to the service, Various records appertaining to regular servicing and re-certification of plant in the home were checked, together with cleaning schedules, medication records, and risk assessments. No areas for concern were found. 2 Cowley Way, DS0000008213.V330863.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 3 ENVIRONMENT Standard No Score 24 4 25 3 26 X 27 3 28 3 29 X 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 3 3 X 3 X X 3 x 2 Cowley Way, DS0000008213.V330863.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. Standard Regulation Requirement Timescale for action 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 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 2 Cowley Way, DS0000008213.V330863.R01.S.doc Version 5.2 Page 28 - 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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