Inspection on 12/10/06 for 23-25 The Warren

This inspection was carried out on 12th October 2006.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

23-25 The Warren 10/01/06

23-25 The Warren 31/08/05

23-25 The Warren 09/11/04

23-25 The Warren 07/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 23-25 The Warren Farthing Hill Ticehurst East Sussex TN5 7QY Lead Inspector Caroline Johnson Key Unannounced Inspection 12th October 2006 13:00 23-25 The Warren DS0000021404.V309812.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 23-25 The Warren DS0000021404.V309812.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. 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 23-25 The Warren Address Farthing Hill Ticehurst East Sussex TN5 7QY 01580 201448 F/P 01580 201448 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) Sussex Autistic Community Trust (Care Services) Limited Stephan Robert Barton Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That only service users with an autistic spectrum disorder may be accommodated. That service users accommodated must be aged between eighteen (18) and sixty five (65) on admission. That the maximum number of service users to be accommodated will not exceed three (3). 10th January 2006 Date of last inspection Brief Description of the Service: 23-25 The Warren is situated on a small housing estate in the village of Ticehurst. The village with its local shops is approximately half a mile away. The home consists of a pair of inter-joining houses each with its own lounge, dining room and kitchen. The home is registered to accommodate three adults with an autistic spectrum disorder. 23-25 the Warren is one of four care homes in East Sussex run by the Sussex Autistic Community Trust. The home makes CSCI reports available to prospective residents and their relatives/representatives upon request. The current scale of weekly charges is £1,635 to £1,827 as at 6 September 2006. 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the inspection process two site visits were undertaken. The first visit was on 12 October 2006 and lasted from 1.00pm till 4.30pm. The second visit was on 20 October and lasted from 1pm until 4.20pm. Over the course of the two visits there were opportunities to meet with the manager, with two staff members and with two of the residents. A tour of both houses was also undertaken. A wide range of documentation was examined including the preadmission assessment carried out in relation to one recently admitted resident, two care plans, staff records, training records, menus and complaints. Following the inspection two of the residents’ relatives were contacted for their views on the care provided in the home. In advance of the site visits comment cards were sent to the service for distribution to the residents. All three residents completed a form and each resident required some degree of support to carry out this task. Comments were positive and residents stated that they liked living in the home although one resident stated that she would like to move. Everyone involved in her care are aware of her desire to move and attempts are being made to find alternative accommodation. Reference was made in the comment cards to activities sometimes not happening due to staffing levels. The manager advised that a new staff rota has been introduced, which should mean greater flexibility and enable residents to participate in more activities. What the service does well: What has improved since the last inspection? Requirements made at the last inspection have been addressed. Record keeping of menus kept in relation to one resident are now more detailed. Two new care staff have been employed. There is still one staff vacancy but the manager reported that with this left vacant this ensures that regular relief staff can be used, which means that the home can more flexibly meet the needs and wishes of residents in relation to day/evening activities. The home has 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 6 introduced a new style staff rota. All of the staff spoken with stated that they were happy with the new rota. The format of the rota makes it easier to document all management hours. 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. 23-25 The Warren DS0000021404.V309812.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 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that prospective residents and/or their relatives are given detailed information about the home. They are thorough when assessing the needs and abilities of prospective residents making sure that they can meet their needs prior to making a decision about accommodation. EVIDENCE: There is a detailed statement of purpose in place, which has been updated recently to include the changes in the staff team. There is currently no information included about the Trust or about the Responsible Individual. The home calls their service user guide a placement agreement. The document includes detailed information about the service provided in the home. The manager advised that the parents of one of the residents recently admitted to the home discussed the document with their daughter prior to admission. Following the inspection a copy of the pre-admission assessment carried out in respect of this resident’’ abilities and needs was forwarded to the Commission. The assessment was very thorough and there was detailed information about the resident including her history and her current abilities and needs. Staff visited the resident on a number of occasions and the resident was invited to the home on at least three occasions, for tea, for dinner and evening and following this for an overnight stay. 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 9 Despite some early transition problems staff reported that the new resident and her fellow house resident are both adapting well now to the changes and are beginning to settle into a good routine. 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning is detailed ensuring that staff are clear about the needs of each resident. Having a system to link risk assessments to guidelines will enhance further what is already a good system. EVIDENCE: Two care plans were examined and they were found to be very detailed and to include specific advice for staff to follow. Information on each of the residents preferred form of communication was also very detailed. In relation to one resident, a new risk assessment regarding the use of restraint in certain circumstances has been introduced. The risk assessment has yet to be signed by the resident’s relatives and care manager. The home was reminded that should restraint be used a copy of the incident report needs to be sent to the Commission. There are a number of risk assessments in place in relation to each resident. It was noted that some of the risk assessments are not very detailed but on further discussion it was found that where this is the case it usually means that 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 11 there are more detailed guidelines elsewhere in the care plan detailing the specific action required by staff. The home continues to use the TEACCH system to aid communication and assist residents to make choices and decisions. Some of the methods used involve the use of either the written word on a card, a picture of an activity alongside the written word, or just a picture of an activity. Each of the cards is laminated and there is Velcro on the back. An example of how the system worked was observed. When a resident returned from her day centre, a staff member used cards with the written word to explain what would be happening, in which order, during the evening. The resident then used the word cards to chose which type of drink she would like. Another method of communicating with this resident is for the staff to ask questions by writing the question and she writes the answer. During the inspection, there was an opportunity to meet with this resident in private and in response to written questions she wrote that she had had her nails painted at the day centre that day, that she loved watching the television and that she was happy living at the Warren. 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to increase the activities provided to residents and due to the complex needs of the residents it is recognised that this is not always an easy task. EVIDENCE: One of the residents attends a course at a local college full-time. In her spare time she enjoys watching football on television, using a computer, watching old movies, playing games and helping with cooking. Another resident, chooses not to attend day care. The home receives a budget for day care and the resident is supported to go out regularly. Staff also support her to budget daily for her meals and to shop for the food. She has recently started swimming once a week and there are plans to increase this to twice a week. She also does a bus and a train journey each week and she enjoys cinema trips. The third resident attends the Trust’s day centre five days a week. Activities include trampoline and aromatherapy. In-house she enjoys watching music 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 13 channels on the TV and using the foot spa. All of the residents are able to make decisions about whether to join in an activity or not. The Trust recently employed a drama teacher to work with one of the residents at the day centre. The drama teacher has introduced a different method for communicating with this resident and as a result this has assisted in improving the quality of her life. An example of this is that this resident, who for the majority of the time chooses not to verbally communicate, but who will write answers when questioned, has for the first time communicated that she is very anxious travelling in the car because she thinks people can see her. As a result of this the Trust has recently leased a new car. The car has darkened windows and sunshades will also be fitted. The manager advised that he hopes to arrange for the drama teacher to work at the home to train staff in the communication used. It is recognised that it could be a very slow process to transfer skills. Residents are offered an annual holiday. One of the residents moved to the home this year, but they had a holiday arranged via their parents, which the home supported by providing staff on a daily basis. Another resident had a holiday at Butlins in Bognor Regis and a third resident chose not to have a holiday but instead had a number of day trips. One of the residents advised that she did not like the fact that staff pass through her lounge and kitchen to get to House 23. The manager advised that the resident was aware of this when they moved into the home and signed a form that they were in agreement. Staff are encouraged to use the front doors and there is a sign on the lounge door to remind staff. There are different arrangements in place for menu planning. Menus are planned for two of the residents, staff prepare the meals and one of the residents likes to assist with cooking. Menus seen were varied and well balanced. The third resident is being supported to budget and plan her meals on a daily basis. She chooses to have a specialist diet and staff support her as best they can. Records of actual meals served show that her diet is not varied and is not always well balanced. The home have discussed this resident’s diet with her gp and are seeking further advice from the learning disability service. 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is good at ensuring that when they need advice and support this is sought and any recommendations received are acted upon. EVIDENCE: At the time of the first site visit the manager reported that one of the residents was overdue a medical review with their psychiatrist. The manager had been in touch with the appropriate people to arrange a review and was waiting on a date. By the second site visit a psychologist had visited the home and arrangements had been made for a psychiatrist to visit. The home had also received input form the community learning disability service (CLDS) in relation to an incident that had occurred in the home and arrangements were also being made for a nurse to visit the home. Recommendations received form the CLDS had been put into practice. A recommendation was made at the last inspection to encourage one of the residents to have her weight monitored either by care staff or her gp. The home has had little success in this and it was noted that the last weight recorded was in April 2005. However, staff reported that the resident has gone up a size in clothes. Staff advised that they would discuss the issue of diet and weight management with a nurse from the learning disability service in the near future. When speaking with the resident’s relative she gave an 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 15 example of how her daughters weight is monitored at home and agreed that this could be shared with the staff team. Feedback was given to the manager following the phone call. A record is kept of the both of the other residents’ weights on a monthly basis. Since the last inspection the home purchased a new medication cupboard. Medication is stored securely and records seen were in order. Staff training on the subject had been booked but did not take place for reasons beyond the control of the home. A new date will be arranged. 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is thorough at investigating complaints and putting in place measures to try to prevent a reoccurrence of similar issues. EVIDENCE: Records showed that one complaint had been made to the home since the last inspection. The complaint was dealt with quickly. Statements were taken and a letter was sent to the complainant with the outcome of the investigations and the action taken as a result. No complaints have been made to the Commission about the service. It was reported that all staff have received training on the subject of adult protection and prevention of abuse. A staff member spoken with was aware of the procedure and was able to describe the action to be taken should an allegation be made. There is also a flow-chart on the wall in the office giving the steps that need to be taken. No adult protection alerts have been made since the last inspection. 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The building is generally well maintained. The delay in redecorating one of the houses is considered sensible until the residents have settled. The need to review the fire risk assessment is essential to ensure the safety of residents. EVIDENCE: In one of the houses the resident took the inspector on a tour around her home. The bedroom was well decorated and had been personalised. The resident advised that she had chosen the colour scheme. She was very proud of her room but stated that she didn’t like the furniture in the lounge or kitchen. She wants to move to alternative accommodation but was aware that this can take time. In the second house there were some dents in the wall upstairs, a towel rail was broken and there was a door to be replaced. The manager advised that this damage had occurred in recent weeks and were a result of both residents adapting to change. The situation had now improved and action would be taken in the coming months to address the work required. There are also plans to redecorate the kitchen. A new chair has also been ordered for one of the residents. 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 18 A staff member carried out a fire risk assessment in June 2006. The manager confirmed that funding had also been agreed to have a more formal risk assessment carried out in the near future. It was also reported that a fire panel system would be fitted with an alert system in both homes. Records showed that fire drills are held regularly. However, one of the residents always refuses to leave the building. As there is only one fire door in the building this is of particular concern and needs to be taken into consideration as part of the home’s risk assessment. It was also noted that when the majority of the fire drills are carried out it is generally the same member of staff and the same resident in the home. All areas of the home seen were clean and there were no unpleasant odours. All of the staff have received training on infection control. 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new staff rota should mean that there is more flexibility and enable more spontaneity with activities. The home is good at ensuring that staff receive regular training to equip them to carry out their roles effectively. EVIDENCE: With the exception of one full time position, all staff vacancies have now been filled. The manager advised that the vacant post has deliberately been left vacant so that they can use regular relief staff flexibly to fit in with the needs of the residents. A new rota system has been introduced. In addition to the normal care package two of the residents receive additional one to one staffing. One resident receives one to one full time and another receives thirty-nine hours each week. These hours are not clearly documented on the rota. The home keeps detailed records of the training provided to all staff. Staff complete a very detailed induction programme. Two of the most recently recruited staff are still working through their induction programme. The majority of the staff have also attended most of the mandatory training courses. The manager advised that staff that have not attended would be booked on the first available course. All staff have had in-house training on medication. It was reported that an external trainer had been booked to 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 20 provide training but then they cancelled close to the due date. This will now be rebooked. In addition to mandatory training the majority of staff have attended courses on autism. The home continues to use the TEACCH system to aid communication with residents and all but two of the staff team have attended a course on the subject. One member of staff is currently studying for an NVQ. Two staff are working through their induction programme and on successful completion their names will be put forward to commence NVQ training Records were seen in relation to two staff employed to work in the home. The home had been thorough in their procedures and records included, application forms, references and identification. CRB checks had also been obtained. Staff meetings are held regularly and records showed that a wide range of topics are covered during the meeting and that guidance to staff is clear. There is a chart on the wall indicating that staff receive regular supervision. Staff spoken with confirmed this. The senior support worker stated that she supervises relief staff. She has received training in this area from the manager and is hoping to receive formal training on the subject tin the coming year. 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed well. They welcome comments made from residents and relatives and the partnership day is a very good opportunity to share ideas and information and to plan ahead. EVIDENCE: The manager has completed NVQ level four in management and care. The recently revised rota system will enable all management hours to be documented on the rota. Staff described the manager as ‘supportive’ and ‘always there to talk to’. The also stated that there is a good on-call system in place. The home has accreditation with the National Autistic Society and this is reviewed annually. The manager reported that this was recently reviewed and feedback received was very positive. 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 22 As part of the home’s quality assurance system, the home as in previous years has arranged a ‘Partnership Day’. In advance of the partnership day, residents and relatives are given a satisfaction questionnaire to complete. Relatives are then invited to attend the home for a meal and a get together with the residents and the staff team and the results of the questionnaires are then discussed along with a proposed action plan to address any issues raised. The manager had almost completed the annual development plan, which will also be discussed with everyone during the partnership day. As part of the inspection process, comment cards were sent to the home for distribution to residents to share their views on the care provided in the home. All of the residents required some degree of support to complete the forms. Overall the responses were positive. However, reference was made to some activities not occurring due to staffing levels. This was discussed with the manager who advised that with the revision of the staff rota, this should ensure that there are always enough staff on duty to facilitate activities. It was also recorded on the comment cards that staff advised the residents that they should speak to the manager if they had a problem. This was discussed with the manager who agreed that residents should chose whom they wish to speak with and this might be any of the staff team. Relatives of two of the residents were contacted to seek their views on the care provided in the home. Both relatives spoken with spoke very positively of the home the staff team and the care provided. One relative stated that since their daughter moved to the home she has settled in gradually and is now much more calm. One advantage of this is that they are now able to take her shopping and she remains calm and the experience is more enjoyable for her and her daughter. Another relative stated that overall `the home do a great job, the care is good and the staff ratios are also good’ as her daughter is taken out every day. Measures in place to ensure the health, safety and welfare of staff and residents include the annual testing of portable appliances and regular tests of fire safety equipment. There is a member of staff designated as the health and safety rep and arrangements are being made for her to attend formal training on the subject. 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 3 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 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 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 3 3 X X 3 X 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 24 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 YA1 Regulation 4(1c) Sec 1 para 1,2 Requirement Information about the Sussex Autistic Community Trust and the Responsible Individual must be included in the Statement of Purpose. The home’s fire risk assessment must include reference to the fact that there is only one fire door and that one of the residents always refuses to leave the building when the alarms sound. All staff and residents must be given the opportunity to take part in drills on a regular basis. Timescale for action 15/01/07 2. YA24 13(4a,c) 15/12/06 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 25 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 YA9 Good Practice Recommendations The risk assessment in place in relation to the use of restraint for one resident should be agreed and signed by the resident’s relatives and care manager. Where there are guidelines in place that link in with a particular risk assessment it should be made clear on the risk assessment to refer to the guidelines. The staff rota should include reference to all one-to-one hours worked. 2. YA33 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 23-25 The Warren DS0000021404.V309812.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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