Inspection on 03/07/08 for 25 Welby Close

This inspection was carried out on 3rd July 2008.

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

Other inspections for this house

25 Welby Close 31/08/06

25 Welby Close 28/10/05

25 Welby Close 26/04/05

25 Welby Close 04/11/04

25 Welby Close 10/05/04

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Fairways

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Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 25 Welby Close 25 Welby Close Maidenhead Berkshire SL6 3PY Lead Inspector Helen Dickens Unannounced Inspection 3rd July 2008 10:00 25 Welby Close DS0000011285.V366936.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 25 Welby Close DS0000011285.V366936.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. 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 25 Welby Close Address 25 Welby Close Maidenhead Berkshire SL6 3PY 01628 824154 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) The Disabilities Trust Mr George Tuffour Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st August 2006 Brief Description of the Service: 25 Welby Close is a residential home offering twenty-four hour care. The home is registered for three residents with learning difficulties. Service users have lived in the home for several years. The service is provided by The Disabilities Trust. The house is situated in a residential area. There are three bedrooms; all of the bedrooms are single and although only one of them has an en-suite facility, the two other residents have their own private bathrooms and toilets. There is also one communal toilet on the ground floor of the home. The home has its own transport. The fees range from £1,270 to £1,657 per week. 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means people who use this service experience good quality outcomes. This key inspection was unannounced though the Inspector spoke with the service manager on the day prior to the inspection to make sure someone would be in. The inspection took place over 5 hours. The inspection was carried out by Mrs. Helen Dickens, Regulation Inspector. Mr. George Tuffour, Registered Manager, represented the establishment. A partial tour of the premises took place and a number of files and documents, including two resident’s assessments and care plans, one staff recruitment file, quality assurance information, and the annual quality assurance assessment (AQAA), were examined as part of the inspection process. The service had an Annual Service Review carried out by CSCI in March 2008 and the results of this review are included in this inspection report. The inspector spoke with one resident several times throughout the day; a second resident did not wish to see the inspector; and the third resident was out. The inspector would like to thank the residents, staff and manager for their time, assistance and hospitality. What the service does well: Welby Close is well-managed and offers a homely environment. There is a friendly and inclusive atmosphere, which benefits both residents and staff. People who live at Welby Close know their assessed and changing needs and personal goals are reflected in their individual plan of care. They are encouraged to make decisions about their daily lives, and to take risks as part of an independent lifestyle. Residents are encouraged to take part in a variety of activities and to be involved in the local community. Family and friendship links are supported and residents benefit by flexible daily routines that enable them to be involved in the life of the home as much as possible. Residents are encouraged to be involved in food preparation, and help choose the menu at Welby Close. People who live at Welby Close receive personal and healthcare support in the way they prefer and require, and are protected by the homes policies and procedures for administering medication. 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 6 Residents can be confident their complaints would be taken seriously, and they are protected from abuse. They are supported by competent staff and protected by the home’s recruitment policies. What has improved since the last inspection? What they could do better: The arrangements for written guidance on safeguarding vulnerable adults must be reviewed so that this is available to staff whilst on the premises – this should include a copy of the local authority’s multi-agency procedures. The shortfalls noted in the gardens, and standards of internal decoration do not currently fit with the otherwise high standards at this home, and it is recommended the provider review this with the housing association who are responsible for the premises. 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 7 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. 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 8 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 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 9 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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service Users made an informed choice about where they wanted to live and have an individual contract/statement of terms and conditions. EVIDENCE: There have been no new admissions to this home since the last inspection. On the Annual Quality Assurance Assessment (AQAA) the manager stated that they have suitable processes in place and will offer prospective service users the opportunity to visit the home before making a decision to live there. It was noted on the two resident’s files examined, that both had a copy of the service user guide and the resident’s contract with the service. 25 Welby Close DS0000011285.V366936.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): 6,7,8 and 9 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents know their assessed and changing needs and personal goals are reflected in their individual plan of care, and they are encouraged to make decisions about their daily lives. Residents are encouraged to take risks as part of an independent lifestyle, but two more risk assessments were needed to fully support residents. EVIDENCE: Two care plans were sampled and found to be well kept with a good record of each resident’s needs and the goals that they were working towards. Both plans demonstrated that residents have a good deal of independence and for example, can read and write, prepare their own breakfasts and lunches, and one goes out alone. As the residents at this home do not need assistance with personal care, care plans concentrated on the other areas where they needed support and supervision, and on encouraging their independence. Reviews were carried out regularly by the home, and copies of social services reviews 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 11 were also kept on file. There was evidence on file that changes suggested at reviews were followed through by staff. Residents at this home are encouraged to make decisions about their daily lives. There were many examples in relation to them going out into the community, choosing where they went and whom they associated with, and how they spent their time whilst at home. The two residents at home on the day of the inspection were observed to move freely within the home and prepared their own light snacks and drinks. One resident goes out without support from staff and is sometimes out until quite late in the evening visiting friends etc. Written guidelines are in place about what staff should do if this resident is not home by 10.30pm. Residents at this home participate in the day to day running of the home and the inspector observed how their views and wishes were taken into account. Up-to-date information is available to residents, and regular home meetings are held – this involves both residents and staff. One or other of the two residents who attend these meetings regularly takes the notes – these notes were seen in the meetings file. User satisfaction surveys are also given to residents to capture their views on the way the home is run and the support they get from staff. Residents are involved in cooking, menu planning, keeping the place clean and tidy, and doing their own laundry. The manager and staff should be congratulated for the way residents are encouraged and supported to participate in the life of the home. Residents are encouraged to take risks as part of an independent lifestyle. As already mentioned, one resident goes out alone to visit friends and participate in the community, for example using the local library. Residents were seen to prepare food and hot drinks, and were encouraged to be independent around the home. Risk management strategies are in place and those risk assessments sampled covered a variety of potential hazards both in the community and within the home. The inspector noted that none of the radiators had covers and an upstairs window did not have a restrictor. The manager said residents were active, and very sensible in relation to these two potential hazards and there had never been any instances of either the windows or the radiators causing harm to a resident. He had believed there was no risk to residents but it was agreed that a written risk assessment would be carried out on both of these matters and a copy was sent to CSCI following this inspection. 25 Welby Close DS0000011285.V366936.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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to take part in a variety of activities and to be involved in the local community. Family and friendship links are supported and residents benefit by flexible daily routines that enable them to be as independent as possible. Residents are encouraged to be involved in food preparation, and they help choose the menu at Welby Close. EVIDENCE: Residents at this home have their own individual activity plans and records are kept of their achievements in relation to further education and activities they enjoy. One resident is currently attending a course on animal management on three days per week at Berkshire College of Agriculture, and staff are helping him to look for some part time voluntary work for when college is closed in the summer. Another resident has started music therapy and enjoys personal shopping sessions, which staff support on a one-to-one basis during the week. 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 13 Residents are part of the local community and use the health facilities, local takeaways and restaurants, and the library. They help with recycling, and they shop locally. Support for individual residents is limited as, during the afternoons and evenings, there is only one member of staff on duty. However, one resident was observed to go out alone, and another was taken out in the morning when two members of staff were available. A third resident was already out for the day. Family and friendship links are encouraged and one resident told the inspector about visiting friends and some of their activities outside the home. The manager said this resident often has friends to visit at Welby Close. Another resident who did not wish to speak with the inspector had regular contact with their family, who they visit and stay with every other weekend-this was documented on their file. Daily routines at this home are very flexible and residents were observed to go into the kitchen when they wanted a drink or a snack, and to move around the home freely. The manager and staff ensure that residents are encouraged to be independent and their care plans record what support is needed to enable this. Staff were seen to knock on resident’s doors before entering, and to speak to them in a respectful manner. Staff were observed to include residents in any conversations they were having, and to ask their opinions. Residents prepare their own breakfasts and lunches, though not everyone can do this without staff support. The weekly menu is posted on the board and this included a variety of foods, which the manager said had been chosen by residents. Staff prepare the evening meal. Overall, main meals on the menu did not look particularly healthy as there were two evenings when chips were served, and another evening when there was going to be a takeaway. However, there were salads and vegetables in the fridge, and the freezer contained lamb chops and mincemeat, as well as burgers. One resident has lost a considerable amount of weight with assistance from staff, and his relative praised the staff for the support they had given on this matter. The manager was asked to ensure that a note was kept of what residents had to eat, irrespective of whether they prepared it themselves, in order to monitor whether overall, they were having a healthy diet. 25 Welby Close DS0000011285.V366936.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 and 20 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents receive personal and healthcare support in the way they prefer and require, and are protected by the home’s policies and procedures for administering medication. EVIDENCE: Residents at this home require only minimal support with personal care and their support plans enable them to be as independent as possible. Their privacy is respected and they choose when they want to wash, bathe, change their clothes etc, as well as what they wish to wear. Each resident has a separate folder which identifies and monitors their healthcare needs. Some have specialist input, for example from a psychiatrist or the occupational therapist, and assessments and reviews from professionals are kept on file. One resident has been supported to lose weight and was pleased to discuss this with the inspector. Health and medication are covered in the twice-yearly reviews carried out for each resident. Regular health checks are offered and resident’s files showed records of visits to the dentist and 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 15 optician. Behavioural management plans are in place for those residents who need this support. Medication arrangements are well organised at this home with the local pharmacy supplying blister packs for resident’s medication. Two medication administration records were checked and found to be satisfactory, with no unexplained gaps in recording. There was documentary evidence that the two residents who are on medication get this reviewed by a consultant every three months. 25 Welby Close DS0000011285.V366936.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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can be confident their complaints would be taken seriously, and they are protected from abuse. However, written policies on safeguarding adults need to be at the service and available to staff. EVIDENCE: There have been no complaints to CSCI in relation to this service since the last inspection. The inspector looked at the complaints log at the home and no complaints have been received there either. There is a complaints procedure in place but residents also have opportunities to highlight any minor issues either to the manager, or at house meetings. They have monthly Regulation 26 visits from the service manager who also speaks with residents and gives them the opportunity to highlight any concerns. It was noted that both residents at home on the day of the inspection had no difficulty speaking up for themselves, and were articulate in getting across their wishes. They would be very able to make a complaint if they had one. The residents at this home are safeguarded from abuse and any reports would be taken seriously. No incidents have been reported to CSCI. Staff have proper recruitment checks, including being checked against the POVA List to ensure they have not been deemed unsuitable to work with vulnerable people. Residents are articulate and empowered to speak up for themselves; all three have families who are in touch on a regular basis. Staff have done safeguarding adults training so would be aware of the procedure to follow. The issue regarding behaviour guidelines highlighted at the last inspection has 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 17 resolved itself satisfactorily. The manager enables residents to keep money securely at the home and one resident’s cashbox and written record was checked and found to be satisfactory. However, written policies on safeguarding were not available on the day of the inspection and the manager was going to get these the next day from head office and the local authority, and ensure they were kept at the service, with a summary version to be highlighted to staff and kept in a place that was easily accessible to them. Some issues relevant to safeguarding adults are discussed in relation to recruitment under Standard 34. 25 Welby Close DS0000011285.V366936.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 and 30 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a homely and comfortable environment though the building itself and the gardens in particular, look neglected. The home is generally clean and hygienic throughout. EVIDENCE: The furnishings and interior of Welby Close offers a homely environment for residents, and the one resident who allowed the inspector to look at their room said they were happy with it and had everything they needed. The living room is comfortable and spacious and new dining furniture and matching coffee tables have been purchased since the last inspection. The home also has a new tumble dryer. The risk assessment in relation to the washing machine, requested at the last inspection, has been carried out. There is a new hob in the kitchen, and the home recently held their first barbecue in the garden. The bushes have been removed from the rear of the back garden, which the 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 19 manager said gives the residents a different outlook, and makes the garden look more spacious. However, there were a number of issues discussed with the manager and service manager some of which they will need to follow up with the Housing Association who are responsible for the maintenance and repair of the property. The home looks rather shabby from the front, and not really in keeping with the other nearby properties. This is because all but one of the window frames has peeling paint, and the garden looks uncared for. The kitchen window, which is plastic, is scratched and needs a good clean. The back garden has recently had a lot of bushes removed but nothing put in their place (and weeds have started to grow) – this makes the garden look neglected. A fence needs repairing and the patio is uneven – a contractor came to look at these on the day of the inspection but said he would have to submit a quote to the Housing Association and have this accepted before work could begin. The manager said this was reported in March. Inside the building there are a number of decorative matters needing attention, in particular, one resident’s bathroom had cracks in the walls/wallpaper from the floor to the ceiling in one corner, and poorly repaired cracks in one wall, with cracks now starting to show through again. It looked as if layers of wallpaper and paint had been used to cover up damaged/cracked walls, which were now in a poor state. The standard of maintenance, repairs and the appearance of the outside of the building fell far short of the otherwise good care and homely atmosphere within the home. The washing machine and tumble dryer are sited in the kitchen and there are arrangements in place to ensure this does not compromise the overall hygiene of the kitchen. The risk assessment requested at the last inspection in relation to the washing machine has been carried out. Residents are encouraged to do their own laundry and there are good hand washing facilities within the home to ensure satisfactory standards of hand hygiene. In the kitchen, the hob, the wall behind the hob, and the extractor fan needed cleaning and the manager said this would be dealt with. The manager was also asked to contact the local authority environmental health department as he said they have never made a visit to the property. 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 20 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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent staff and protected by the home’s recruitment policies. Residents are supported by appropriately trained staff. EVIDENCE: The staff at this home are employed by the Disabilities Trust who hold the Investors in People Award until 2010. Staff were observed to communicate well with residents, and to be knowledgeable about their individual needs. Of the three permanent care staff, two already have NVQ qualifications, one having an NVQ Level 3, and the other an NVQ Level 4, both in Care. The new staff member is waiting to enrol on an NVQ course. Of the regular Bank staff, one has a nursing qualification. There is a low staff turnover at this home and one recruitment file was sampled for the new permanent member of staff taken on since the last inspection. There was an application form, a good record of the interview, and a full employment history. Two references had been taken up but there was discussion about whether one had been sought from the last employer – given 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 21 some employment dates overlapped. The manager said he would follow this up. Evidence of CRB and POVA checks are kept at head office and there is usually a letter on file at the service, from the head office, to show these checks have been carried out. This was missing from the file sampled but it was possible to see from other documentation in the recruitment file that these checks had been carried out. This was discussed with the manager and service manager who said that this would be rectified. Each staff member has a training record showing courses taken and what refresher training is needed. One training record was sampled and the staff member found to have completed all the basic training, for example protection of vulnerable adults, fire safety, moving and handling, food hygiene, and health and safety. They had also completed an autism awareness course. The manager said all staff receive induction training and one file was sampled and found to be satisfactory in this regard. There is an overall training plan and a training budget which ensures suitable training opportunities are made available to staff. 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 22 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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. This home is well managed and resident’s views are taken into account in the quality assurance processes. Health and safety monitoring arrangements are in place to promot the safety and welfare of residents. EVIDENCE: The manager has been in post since 1999. He has the NVQ Level 4 and the Registered Managers Award. He also has the Diploma in Advanced Management for Care. He ensures the home is properly managed, including the budget, and he reports to a service manager within the Disabilities Trust. Management responsibilities within the home were clear and the manager has ensured that there is pleasant and friendly atmosphere within the home, which benefits both residents and staff. 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 23 The home has quality assurance processes in place to ensure the quality of the service is monitored and resident’s views are taken into account. For example there are Regulation 26 visits on behalf of the provider, and regular house meetings – two residents take it in turns to take notes at these meetings. There is a dedicated person at Head Office who oversees all quality assurance monitoring at each home. There is regular monitoring of resident’s care at Welby Close, and each resident has their own annual development plan. There is also a business plan for the home. The recommendation made at the previous inspection relating to an annual development plan is therefore considered to have been met. There are a number of measures in place for ensuring the health and safety of residents at this home including 3-monthly health and safety visits from a dedicated health and safety officer from the Disabilities Trust. Daily health and safety checks are carried out by staff, for example monitoring of water temperatures within the home. There are some weekly checks, including a weekly fire log and fire alarm testing. The home was displaying their car insurance certificate and public liability insurance certificates. Their care home registration certificate was out of date in that it was issued during the time of the National Care Standards Commission. The manager was asked to take a copy of this for display, and to return the original to CSCI Registration Unit for an up-dated certificate. Issues relating to risk assessments and an overdue visit by the local environmental health department are dealt with earlier in this report. 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 24 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 4 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 X 3 X X 2 X 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 25 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 In addition to the existing staff training on safeguarding adults, copies of the relevant written policies must be kept at the home, and these should be made known to and easily accessible to staff. Timescale for action 10/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA24 Good Practice Recommendations The provider should review the current shortfalls in relation to the garden and internal decoration with the Housing Association responsible for the premises, and ensure these shortfalls are remedied in a timely fashion. See Standard 24 of this report for details. 25 Welby Close DS0000011285.V366936.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 25 Welby Close DS0000011285.V366936.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. 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