Inspection on 09/11/06 for 26, Cross Street

This inspection was carried out on 9th November 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

26, Cross Street 19/01/06

26, Cross Street 25/08/05

26, Cross Street 18/11/04

26, Cross Street 25/05/04

26, Cross Street 13/01/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 26, Cross Street Hampton Hill Middlesex TW12 1RT Lead Inspector Sandy Patrick Unannounced Inspection 9th November 2006 09:30 26, Cross Street DS0000017360.V319250.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 26, Cross Street DS0000017360.V319250.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. 26, Cross Street DS0000017360.V319250.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 26, Cross Street Address Hampton Hill Middlesex TW12 1RT 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) 020 8783 0973 020 8783 0973 London Borough of Richmond upon Thames Mr James Edward King Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 26, Cross Street DS0000017360.V319250.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: 26 Cross Street is a care home providing care and accommodation for up to four people who have a learning disability and sensory impairments. The building is owned by London Quadrant Housing Association. The service is run and managed by the London Borough of Richmond. The home is a bungalow situated in Hampton Hill. It is close to local shops, pubs, community facilities and public transport links. Bushey Park is within walking distance. Each person has their own bedroom. The internal layout of the building and the services offered are designed to meet the needs of people who have a sensory disability. The Registered Persons have produced a Service User Guide, which includes information on the aims and objectives of the service. The cost of the placement varies for each person and based on individual assessments of need. The people who live at the home pay a contribution towards this. 26, Cross Street DS0000017360.V319250.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 9th November 2006. The Inspector met with two of the people who live at the home and one person who has started to use the service but had not moved in at the time of the inspection. The Inspector also met the Manager, Deputy Manager, staff on duty and visitors. The Inspector was made welcome by everyone and was invited to join them for their midday meal. The staff on duty showed respect and kindness towards the people who live at the home and the atmosphere was relaxed and friendly. The Inspector spoke to people who live at the home, staff and visitors and looked at some of the records used at the home. Before the inspection the CSCI wrote to the people who live at the home, their relatives, staff and other professionals asking them to complete surveys about the home and their experiences. Two of the people who live at the home and five members of staff returned surveys. Both of the people who live at the home said that they were happy there and that they had been able to make choices about moving to the home and in their everyday lives. They said that the staff treated them well and that they knew what to do if they wanted to make a complaint. They said that the home was clean and fresh and that they were well cared for. Some of the issues that staff raised are discussed in more detail in the ‘Staffing’ Section of this report. The staff were asked what they felt the home did well. Some of the things they wrote were, ‘very good healthy diet for all residents’, ‘there are many things I feel we do well at Cross Street. We provide a caring environment where people feel at home and have freedom to make choices and express themselves. This is a very positive place to work’, ‘we focus on individual needs’, ‘we provide a good continuity of care’ and ‘the people who live here are very happy’. The staff were also asked to write what changes they felt would improve the home. Some of the things that they said were, ‘better funding to provide specific day services’, ‘to have better resources’ and ‘to improve the team working’. What the service does well: Everybody at the home is treated equally and everybody has an important part to play. Everybody respects each other. The staff support the people who live at the home to do the things that they want to do. 26, Cross Street DS0000017360.V319250.R01.S.doc Version 5.2 Page 6 People are happy living there. The food is fresh, well prepared and tasty. The staff know the people who live at the home well. The house looks nice and the people have personalised it. The staff make sure everybody get the support and help they need from other professionals. 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. 26, Cross Street DS0000017360.V319250.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 26, Cross Street DS0000017360.V319250.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): 1, 2, 3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who are thinking about moving to the home are given a range of different information and are able to visit and spend time there. The staff work closely with other professionals to make sure they know about the needs of people who are thinking about moving there. EVIDENCE: There is a suitable Statement of Purpose and Service User Guide. These include information to help people who are thinking about moving to the home and their families to make a decision about this. There was one vacancy at the time of the inspection. A person who had been assessed for this place was starting to spend time there each day. This gave them, the people who live at the home and the staff the opportunity to get to know each other. The Manager said that they hoped this person would start spending nights there in the near future. The person has been given a room and has started to put some of their possessions in this to personalise it. 26, Cross Street DS0000017360.V319250.R01.S.doc Version 5.2 Page 9 The staff have a range of information from other professionals to help them get to know the new person and also guidelines which the Manager has developed. Some information needs updating to include guidelines on different needs. The Manager said that they are updating this as they get to know the person better. The Manager and staff work closely with other care professionals to support people to meet their individual needs. The home specialises in caring for people with sensory needs, and on the day of the inspection people from a national signing organisation were helping translate and support understanding between the staff and the new person. They visit the home regularly to offer this support. The staff are also trained in Makaton. The Inspector spoke to a relative of one person. They said that they felt the staff were very kind, caring and supportive. 26, Cross Street DS0000017360.V319250.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Everyone has helped to record their individual needs and wishes in care plans which are regularly reviewed and updated. The staff support people to try new things and look at how risks can be minimised. The staff help people to communicate. Some of the information and records could be made more accessible. The people who live at the home should be more involved in choosing the staff who work with them. EVIDENCE: A care plan has been developed for each person. This describes their main needs and the support the staff should give them. The people who live at the home have been involved in the development of their own care plan and help review these monthly. Each month the individual and their keyworker set new 26, Cross Street DS0000017360.V319250.R01.S.doc Version 5.2 Page 11 goals which aim to meet their needs and wishes. The care plans include staff action to meet these goals. Each person has an annual review involving the people who they feel are important in their lives. The Inspector looked at the information for one person’s review. This was written by the person themselves and included their own pictures and information about their achievements and feelings. The document was attractive and an excellent example of supporting individuals to take control of their own lives. People are encouraged to take risks and try new things. Risk assessments are in place to help staff to enable them to do this. Risk assessments have been made where people have had a change in need and may be at risk during certain activities. The risk assessments focus on skills and maintaining independence where possible. The communication needs for the people who live at the home vary. The staff have been trained in Makaton and use this to help them communicate with some of the residents. One person has a visual impairment. In house procedures include keeping the environment hazard free and not moving furniture without explaining this to this person. The staff work with individual people to support them with their communication needs and to help them communicate with each other. Care plans identify changes in need in this area and give clear instructions to staff. A national organisation provides signers who support the person who is moving to the home to communicate with the staff. The staff need to improve their signing and some staff need to improve their Makaton skills to improve direct communication. Training has been organised in this area. Some of the records and information include words and pictures that the people who live there find easier to understand. This is good practice and the Manager and staff should look at how more information can be made accessible. One person has a visual impairment and the Manager and staff should think about ways they can make documents more accessible for them. Accessible documents and information should be kept somewhere that the people who live there can access whenever they need. Some people have been involved in writing their own reviews. In the past they have created meeting minutes, newsletters and other documents to share with relatives and friends. This has not happened recently and it would be good for them to start doing this again. 26, Cross Street DS0000017360.V319250.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): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People are supported to participate in a wide range of activities and educational opportunities of their choice. They are valued members of the local community and have friendships and relationships outside of the home. The staff treat the people who live at the home with respect and kindness and recognise their rights. There is a good range of nutritious and wholesome food which well prepared. The staff place a high value on making sure high quality food is varied and tastes good. 26, Cross Street DS0000017360.V319250.R01.S.doc Version 5.2 Page 13 EVIDENCE: The staff have given people support to have good self awareness and to be independent where they can be. People who live at the home have made positive achievements since they moved there. Everybody has full lives which include a range of different activities designed to meet their needs and choices. These include attending local college courses, swimming, cycling, aromatherapy and meeting with friends through social groups. Each person organises what they want to do with their keyworker and this is reviewed on a regular basis. Records show that people take part in a wide range of activities and outings. Everybody takes part in household tasks and chores according to their needs and abilities. Everyone is involved in menu planning and shopping. Different people do different tasks such as recycling, cooking, laundry and cleaning. The ethos of the home is to involve everyone and examples of this were seen during the inspection and previous visits. Throughout the day staff consulted with everybody and involved them in the day-to-day activities and leisure activities of their choice. The people who live at the home have lots of friends who live elsewhere. They attend a variety of clubs and social events and friends and family visit them. Some people attend local places of worship and celebrate their religious needs. Care plans identify individual cultural and religious needs and how these can be met. A number of special events, parties and holidays are organised throughout the year according to the wishes of individuals. The staff treat everybody with respect, offering them choices and giving them the information that they need to make those choices. People are called by their preferred names and staff respect their privacy and knock on bedroom doors before entering. The Inspector saw examples of the staff showing genuine fondness for the people who live there, listening to their opinions and acting upon these. The food is all freshly bought and prepared. Everybody is committed to healthy eating and recognise the importance of healthy and wholesome food. Fresh fruit and vegetables are available throughout the day. The people who live at the home are involved in preparing meals, and the staff who support them are competent cooks. Staff who spoke about food showed a passion for 26, Cross Street DS0000017360.V319250.R01.S.doc Version 5.2 Page 14 this and a commitment to making meals healthy and tasty. They talked about the importance of making food attractive and using smells and colours. The Inspector was invited to join everybody for their midday meal. This was well prepared with fresh and tasty ingredients and was enjoyed by everyone. 26, Cross Street DS0000017360.V319250.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personal and health care needs of the people who live at the home are recorded, monitored and met. There has been some excellent work to make sure people stay in good health. Medication is appropriately managed. EVIDENCE: Personal care needs are recorded within care plans and the staff demonstrated a good understanding of how to maintain privacy and dignity. People have a variety of health care needs. The staff work closely with other professionals to make sure these needs are met. Some people have had improvements in their health because of their own commitment and the support of staff. 26, Cross Street DS0000017360.V319250.R01.S.doc Version 5.2 Page 16 The Manager and staff have advocated on behalf of the people who live at the home with health care professionals and have worked hard to make sure individual needs are met. One person was in hospital at the time of the inspection. Everybody took it in turns to visit them daily. There is a suitable medication procedure and medication is stored securely. Records of receipt, administration and disposal of medication are kept and are accurate. The supplying pharmacist makes regular visits and offers advice and support. A homely remedy (non prescribed medication) policy has been signed by the GP. 26, Cross Street DS0000017360.V319250.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are appropriate procedures regarding complaints and protection. EVIDENCE: There is a suitable complaints procedure which includes information on timescales and how to contact the Commission for Social Care Inspection. There is a record of complaints which includes action taken to investigate and address these. There have been no formal complaints since the last inspection. However the staff spoke about some informal concerns. Informal concerns and any action taken to remedy these should be recorded. The London Borough of Richmond has a protection of vulnerable adults procedure. The staff have had training in this area. Criminal record and reference checks are made on all staff before they commence employment. Everyone has their own bank accounts. They have a safe place to keep small amounts of cash. The staff support anyone who needs help to manage this. On the day of the inspection the Inspector saw a staff member supporting one person to pay for their aromatherapy. The staff helped to explain the situation to the person. Accurate records of transactions are kept. 26, Cross Street DS0000017360.V319250.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, 26, 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is a suitable design, attractively decorated and well maintained. The people who live there have individual rooms and have personalised the home. Equipment is well maintained and the home is kept clean. EVIDENCE: The home is a bungalow on a quiet residential road in Hampton Hill. Everyone has their own bedroom and these have been personalised. There is a well equipped bathroom, a separate WC, a utility room, a lounge/diner and an office. People have unrestricted access to communal areas. The home is attractively decorated and personalised throughout. There is a well maintained garden. Some new furniture has been brought since the last inspection and this is in keeping with the rest of the home. Since the last inspection the kitchen area has been changed. There is new separate door to the kitchen and a breakfast bar to the lounge/dining room. 26, Cross Street DS0000017360.V319250.R01.S.doc Version 5.2 Page 19 The staff said that the changes had been an improvement and that everyone could sit at the breakfast bar and help prepare food. The actual kitchen area is fairly small and before the changes it was difficult for more than one person to work comfortably in the kitchen. The home is very clean and fresh throughout and well maintained. The people who live and work at the home take a pride in the environment. 26, Cross Street DS0000017360.V319250.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): 31, 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. There is sufficient number of staff and they are committed to supporting the people who live at the home. The Manager needs to make sure the staff feel supported and have the training they need to undertake their jobs. EVIDENCE: There are suitable number of staff employed. They work shifts as part of a rota and there is always at least one member of staff on duty. One member of staff sleeps at the home during the night. The Manager said that staffing levels were being reviewed and additional staff would be provided to meet the needs of the new person. The staff team have worked at the home for some time and know the needs of the people who live there well. They have consistently shown that they are dedicated to meeting individual needs and supporting each person to achieve personal goals. The staff are friendly, kind and genuinely care about the wellbeing and feelings of the people who live there. 26, Cross Street DS0000017360.V319250.R01.S.doc Version 5.2 Page 21 The London Borough of Richmond has sound recruitment procedures which make sure thorough pre employment checks are made on all staff. The Manager should consider ways the people who live at the home could be more involved in the recruitment of staff in the future. Some of the staff said that they did not have regular formal supervision meetings and that they would like to have this more often. The Deputy Manager said that it was difficult arranging these, as it was a busy time, however they recognised the importance of these meetings. Records of individual supervision meetings are accessible to all staff and must be stored securely so that staff feel confident that the conversations they have are confidential. Staff criminal record checks are kept in unlocked cabinets and must be stored confidentially. Some of the staff said that there was good informal support for each other, but others felt that this was not enough. Some of the staff felt that they had been less supported over the last year than they had been in the past. Some of the staff felt that they were not listened to or included in decision making. Some staff felt that they would like more direction and support in their role. Some of the staff said that they did not have regular team meetings and that when they did they were not able to contribute to the agenda. The Inspector spoke with the Manager who agreed to hold formal staff meetings and individual supervision meetings more regularly. This is important and the Managers must make sure the staff team feel supported. This is particularly important during periods of change when the staff may feel unsettled. It is important that the staff feel able to contribute their ideas and opinions and understand why decisions that they do not agree with have been made. The staff have achieved or are working towards NVQ qualifications. The staff who spoke to the Inspector and those completing questionnaires said that they had not really had a lot of training recently and some said that they had not had any for over a year. Some staff said that they had updated key training in first aid. The Manager must support individual staff to identify and meet their training needs. Individual training profiles should be maintained and updated. There should be support to help the staff to continuously develop their skills and knowledge. There are also identified needs for the staff team to improve their signing and Makaton skills to help them communicate with the person moving to the home. The Manager said that this training had been arranged. 26, Cross Street DS0000017360.V319250.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, 38, 39, 41 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is appropriately managed and the Manager is qualified and experienced. There are suitable procedures for measuring quality and checking health and safety. Record keeping at the home should be improved. EVIDENCE: The Manager has worked at 26 Cross Street since it was registered. He has an excellent knowledge of the individual needs of the people who live at the home and has consistently shown a commitment to providing the best service for each person. He is appropriately qualified and keeps himself updated with good practice guidance. 26, Cross Street DS0000017360.V319250.R01.S.doc Version 5.2 Page 23 Most of the staff who spoke about the Manager praised his management style and said that they felt he was a good advocate for people. Some staff said that they felt their opinions were not always listened to and they would like more opportunity to contribute their ideas. This was discussed with the Manager who agreed to look at ways to support staff more in this area. There have been a small number of incidents, which the Manager should have notified the CSCI about. These include physical assaults of a visitor and a member of staff. The Manager must make sure the CSCI is notified of any such incident and also any incident which affects the wellbeing of people who live at the home. Monthly quality inspections by the Area Manager look at different aspects of care at the home. These focus on one specific area at each visit and include looking at rights, choices, equality and diversity, food and activities. Reports from these visits are sent to the CSCI. The London Borough of Richmond has worked with service users across the borough to develop standards to measure quality in the services people use. The people who live and work at 26 Cross Street have been involved with this work. Some of the records are rather disorganised and need to be updated and reorganised. Some information needs to be archived. Certain records need to be made more accessible. Health and safety, including fire safety is maintained and some information on checks of equipment is recorded. However, these records need to be kept up to date and better organised so that checks on fire safety, water safety, first aid supplies, equipment and general health and safety are clear and easily accessible. 26, Cross Street DS0000017360.V319250.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 3 2 3 3 3 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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 2 3 X 3 3 X 26, Cross Street DS0000017360.V319250.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 YA36 Regulation 18(2) 12(5) Requirement Timescale for action The Registered Person must 31/01/07 make sure all staff receive regular individual supervision. The Registered Person must make sure the staff have opportunities to participate in regular formal team meetings and that they feel able to contribute to these. 2. YA35 18(1)(c) The Registered Person must 31/03/07 support staff to identify training needs and should keep training profiles up to date and accurate. The Registered Person must 31/12/06 make sure staff supervision records and criminal record checks are stored confidentially. The Registered Person must 31/12/06 make sure the CSCI is notified of any event which affects the well being of the people who live or work at the home. DS0000017360.V319250.R01.S.doc Version 5.2 Page 26 3. YA36 17(1) 12(5) 4. YA38 37 26, Cross Street 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 YA7 Good Practice Recommendations The staff should consider how to make more information accessible to the people who live at the home. The staff should consider ways to support the people who live at the home to be more involved in developing newsletters, other documents and in choosing the staff who work with them. Informal concerns and any action taken to remedy these should be recorded. Some of the records, including health and safety records need to be reorganised so that information is clearer. 2. YA8 3. YA22 4. 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