Inspection on 20/09/05 for 26, Egerton Road

This inspection was carried out on 20th September 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

26, Egerton Road 08/02/07

26, Egerton Road 26/01/06

26, Egerton Road 02/02/05

26, Egerton Road 19/07/04

26, Egerton Road 18/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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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 Egerton Road 29 Egerton Road Twickenham Middlesex TW2 7SP Lead Inspector Sandy Patrick Unannounced 20 September 2005 th 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 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 Stationary 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. Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Egerton Road Address 26 Egerton Road Twickenham Middlesex TW2 7SP 020 8891 6308 020 8744 9478 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) London Borough of Richmond Upon Thames Kimberley J Poulter-Dell Care Home (CRH) 6 Category(ies) of Learning Disability (LD) 6 registration, with number of places Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 2nd February 2005 Brief Description of the Service: 26 Egerton Road is a residential care home providing short term accommodation for up to six adults with a learning disability. The service is managed by the London Borough of Richmond. Staffing levels reflect the needs of the service users who are accessing the service at any given time. Staffing is provided over twenty-four hours. Over forty service users access the service throughout the year. The average stay at the home is for up to three weeks at a time. Some service users remain at the home for longer if there is a specific need, for example they are waiting for another longer term placement. The home is situated in a quiet residential road and is in keeping with the neighbouring houses. Whitton and Twickenham town centres are a short distance away. The area is well service by transport links and local amenities. The Registered Persons have produced a Statement of Purpose , which includes information on the aims and objectives of the service. Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 20th September 2005, and was unannounced. The Inspector met with the Manager, other staff on duty and three service users who were staying at the home at the time of the inspection. The Inspector was made welcome by all. The atmosphere at the home was relaxed throughout the inspection. One service user who was unwell was cared for by staff. Service users reported that they liked staying at Egerton Road, that the staff were kind and helpful and that they had opportunities to participate in a range of activities. What the service does well: What has improved since the last inspection? New service users have started to use the service. There has been a wide range of activities which many of the service users have participated in. Work to produce a range of accessible documents has taken place. These include a new Service User Guide, information leaflets, safety notices and a missing person procedure. Staff and service users are working together to create accessible person centred plans and a complaints procedure. All risk assessments have been reviewed. New care plans have been developed. Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 Page 6 The staff have extended links to other services, including children’s services. Two staff have started work and completed their induction. The staff team have worked well together and have come up with a number of ideas to develop the service. The Manager and one member of staff have completed their NVQ qualifications. There have been improvements to the environment and facilities in communal areas and bedrooms. There have been improvements to record keeping. 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. Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 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 standard(s) 1, 2, 3 & 4 Potential service users are able to access a wide range of information and meet with staff and other service users so that they can understand what the service can offer them. Service users are able to visit the home and participate in the service at a pace which suits them. The Manager and staff work closely with potential service users and their representatives to assess what they want and need from the service. EVIDENCE: The home offers a service for approximately forty service users throughout the London Borough of Richmond, and on occasions neighbouring boroughs. There is a very wide range of needs amongst the service users, from those who have recently moved from children’s service to older people who have a learning disability. Service users have differing personal, health, social, emotional, intellectual and educational needs and the service needs to accommodate these. The staff team have consistently demonstrated an in depth knowledge of the needs of various service users, including health care, social and dietary needs. The staff on duty told the Inspector that they enjoyed the challenges of working with such a diverse group. Two bedrooms at the home are designed Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 Page 9 to meet the needs of service users who are more physically dependent. There is evidence that staff at the home have a range of information and training to support them in their roles. The staff work closely with the Community Team for Learning Disabilities, day services and families to ensure a holistic approach to care. The Registered Person has produced a comprehensive Statement of Purpose, which includes the required information. The staff team have been working on the development of a new Service User Guide. This document includes text, photographs, pictures and symbols. Service users have been invited to participate in the development of this. The Manager stated that the draft of the Service User Guide was going to be shown to the service user group at their next meeting so that they could comment on the design and content before it is finalised. The staff team area also developing other documents to promote the service and provide information to service users, their families and other interested parties. The staff team are particularly keen to promote the service to younger adults who may have recently left children’s services and school. They are therefore liaising with schools, children’s social work teams and young people to give them information about the service. This has included written information and meeting with various parties. The Manager showed the Inspector that she had researched various different leaflets and information from other social services in London to get ideas to help with the development of the information to promote Egerton Road. The staff team have consulted with service users and have asked for their help and involvement in creating this information. The Manager reported that over the last six months, the staff team have met with lots of younger people who are interested in the service. Potential service users are invited to participate in activities which are organised on a regular basis and to service user meetings. If they are interested in staying at Egerton Road they are invited to visit the home, first for a meal and to meet other service users and staff and then for an overnight stay. During these meetings the Manager and staff develop assessments of need which will help identify the type of service each person wants and needs. Copies of assessments were seen by the Inspector. Information from the service user, their family, social workers and health care professionals was included within assessments. Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 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 standard(s) 6, 7, 8 & 9 Service users have their individual needs recorded and are working with staff to develop person centred plans. Service users are able to make choices about their participation in the service and are consulted about changes and developments. Service users are supported to take risks and these have been appropriately assessed. EVIDENCE: Since the last inspection, the Manager and staff team have developed new service user plans for all service users. These are designed to give guidance to staff to meet individual needs. The Inspector examined three of these. The plans were comprehensive and care notes made during each service user’s stay indicated that plans were followed appropriately. The Manager reported that there are plans to developed individual person centred plans with each service user. These will represent the service users’ wishes and needs and be produced in formats appropriate to each person. Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 Page 11 The staff team have done a great deal of work using computer packages and digital cameras to produce a range of accessible information. Staff are becoming skilled in using different methods of communication and plan to use these skills in the development of person centred plans. The team have produced a new Service User Guide, leaflets about the service and a hazard analysis for the kitchen in different formats. They have produced these in consultation with service users. Work is also taking place to produce comment cards and other information for service users. The staff on duty spoke enthusiastically about this work and spoke about the ways in which they seek the views of service users. Assessments of risk are in place for all service users and these have been reviewed and updated since the last inspection. There was evidence of consultation with other professionals where appropriate. The staff team have received training in Makaton and use this to support communication where appropriate. Regular service user meetings are held. These are open to all users of the service. Minutes of meetings indicate that there are open discussions and that service users are well informed and appropriately consulted. Service users were invited to a summer party and photo shoot where they participated in a range of photographs around the home, which will be used to enhance leaflets and information on the service. One member of staff has developed information on each individual to be used in conjunction with the missing person procedure. Forms for each service user with photographs and key information have been developed. This work is very good. Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 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 standard(s) 11, 12, 13, 14, 16 & 17 Service users are supported to develop and maintain skills and to have new experiences. Service users are supported to continue with their normal activities, such as attending college and day services. Service users participate in the planning and preparation of meals and the provision of activities. EVIDENCE: Service users are supported to participate in household task, menu planning, shopping and cooking whilst they stay at the home. Individual service user plans record needs and wishes. The service users who met with the Inspector reported that they were able to make choices and participate in household activities. Service users are supported to carry on with their normal activities such as attending college or resource centres whilst they stay at the home. The staff Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 Page 13 work closely with other services to ensure a holistic approach to care and support. Each service user is allocated a Link Worker who coordinates their support. The home is located close to Whitton and Twickenham town centres and is well served by public transport links. Service users are supported to access community facilities and to have a positive presence in the local community. Many of the service users live locally and are able to maintain community links whilst staying at the home. The Manager reported that service users are supported to attend local places of worship as required. The staff and service users plan and organise activities according to individual needs. Activities include trips to local pubs, cinemas, meals out and activities within the home, such as cooking, craft and videos. All bedrooms are equipped with TVs and videos or DVD players. There is a wide range of music, videos and DVDs available to service users and they are encouraged to bring their own whilst they stay at the home. The staff also manage and run activity groups for all service users throughout the year. Since the last inspection there have been a number of outings including to wild life parks, sports and music events, boat trips and local events such as the cinema and meals out. The staff on duty reported that they had pre arranged some activities, however the majority of activities had been decided on the day by the service user group. A summer party was organised and a special event for Halloween is being planned. The service caters for a wide range of different needs. Various members of staff have different responsibilities and these include the organisation of a range of activities to meet the needs of different service users. One member of staff has been researching and providing activities specifically for the older service users. Others have been working with the young adults who are new to the service. Procedures ensure that staff knock on service users doors before entering and to show respect for privacy and use preferred forms of address. Service users have unrestricted access to all communal areas of the home. Service users’ wishes and needs are clearly identified in care notes. Preferred rising and retiring times and preferences regarding personal care are recorded. Service users are able to self medicate and have keys for their rooms and the house if appropriate and they wish to. Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 Page 14 Staff reported that menus are chosen on a daily basis by the service users residing at the home at any given time. The home caters for a range of dietary needs and the Inspector saw special arrangements for food and storage to meet individual needs. Menus for the home indicate choice, variety and nutritional balance. Staff reported that fresh food is brought daily and there is an emphasis on buying quality products. Supermarket value ranges are not used within the home and all meals are freshly prepared. Cupboards, fridges and freezers were well stocked with a wide variety of food. Staff reported that service users were encouraged to help themselves to snacks, as they would in their own home. Staff on duty demonstrated a good understanding of different dietary needs, both for health and cultural reasons. Food allergies are clearly highlighted on staff daily shift plans. Service users are supported to be involved in meal planning, shopping and preparation. Staff reported that they considered food an important part of supporting service users to feel at ease and comfortable with their surroundings. They therefore liaise closely with service users and their families about individual preferences prior to admission. On the day of the inspection, the service user who remained at the home for the day helped themselves to lunch which they chose and made. Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Individual personal, health care and medication needs are appropriately recorded, monitored and met. EVIDENCE: Personal and health care needs are recorded within individual service user plans. The home work closely with the Community Team for Learning Disabilities and other health care professionals to ensure that individual needs are met. Care notes indicate that individual needs are monitored and met. There is an appropriate procedure regarding medication. All staff have received training in administration of medication. Further training for the whole staff team has been organised with the Pharmacist to take place shortly after the inspection. All medication is stored securely. Service users who normally administer their own medication are encouraged to continue to do so whilst staying at the home. However, are not able to hold their own medication as this is considered too great a risk. Medication administration records are appropriately maintained and service user plans indicate individual medication needs. Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 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 standard(s) 22 & 23 There are appropriate procedures regarding complaints, protection of vulnerable adults and whistle blowing. These are designed to protect service users and uphold their rights. EVIDENCE: There is an appropriate complaints procedure detailing timescales and information on how to contact the Commission for Social Care Inspection. The Manager and staff are working with service users to develop a new complaints procedure which will be clearer and more accessible to people who may find the written procedure difficult to understand. There have been no complaints since the last inspection. The Manager maintains a record of comments and feedback from service users and other parties. There were a number of recorded compliments stating that the service was well run and that staff were kind and supportive. The Manager and staff team are working with service users to develop a ‘comment card’. Service users will be able to record their views following a stay at the home. The Manager reported that these comment cards will be used to monitor service delivery and look at ways to improve the service. The London Borough of Richmond have suitable procedures for the protection of vulnerable adults and whistle blowing. Staff have undertaken relevant training. Pre employment checks, including criminal record checks, are made on all staff. There is a suitable procedure for the storage and handling of money belonging to service users. Service users are encouraged to manage their own finances with the support of the staff. Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 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 standard(s) 24, 25, 26, 27, 28, 29 & 30 The environment meets the needs of a wide range of service users and provides a homely and attractive environment for people to stay in. EVIDENCE: Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 Page 18 Accommodation is provided on two floors in a detached property. The home has two driveways but roadside parking is restricted. There is a small garden to the rear of the home. There are appropriate number of bathrooms and communal facilities. Over the past two years the majority of the home has been redecorated and new furnishings and fittings have been purchased. The ground floor has been equipped with new flooring and there is new furniture in private and communal rooms. The home is looks attractive and welcoming, with flowers and pictures throughout. The garden is due to have a decked area to replace the current patio. The outside of the house has been made attractive with hanging baskets and other flowers. The Manager reported that there were plans to purchase new mattresses for some beds and a new dining room table. At the time of the inspection, the oven was not working properly. This was due to be repaired. The staff spoke about how they had provided hot meals since the oven had broken. All bedrooms are for single occupancy. One bedroom is smaller and does not contain a hand washbasin. Service users have appropriate information regarding this room prior to admission. Staff reported that this room meets the individual needs of some of the service users. All bedrooms are appropriately furnished and equipped. Service users are able to bring their own belongings to personalise rooms during their stay. Service users are able to make choices about the bedroom they wish to occupy, and the home try to accommodate this choice, providing their needs can be met in this room. All bedrooms seen by the Inspector were attractively decorated and comfortable. The building is equipped with grab rails throughout. Two bedrooms have been especially adapted to accommodate service users who are physically dependent. Both rooms have ceiling track hoists leading to a bathroom. Al bedrooms are equipped with a call bell system. The kitchen is equipped with adjustable surfaces and there are low-level light switches throughout. The home was clean and tidy throughout on the day of the inspection. Staff were seen cleaning and there are suitable procedures for household tasks. There are appropriate procedures regarding infection control and in relation to Control of Substances Hazardous to Health. Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 & 26 The service users are supported by a full staff team, who have been appropriately recruited, inducted and trained. The staff team are appropriately supported and are able to contribute to the running of the home. EVIDENCE: The home was fully staffed at the time of the inspection. There are eight permanent members of staff and a team of bank and part time staff who help facilitate activities, service user meetings and support at the home as necessary. Staffing levels are assessed according to individuals who are living at the home at any one time. Generally two or three staff are employed from 7am until 10pm. A member of staff sleeps at the home over night. Waking night staff and more day staff are employed when there is a need. Two members of staff have commenced employment since the last inspection. They had both completed their induction and the Manager reported that they had settled in well. Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 Page 20 All staff have been issued with contracts and job descriptions and there is a wide range of additional information about their roles and responsibilities at the home. The Manager and one other staff member had completed their NVQs shortly before the inspection. The two new members of staff were due to commence their NVQ Level 3 in the next few months. There is an appropriate procedure for the recruitment of staff and records examined indicated thorough checks prior to the commencement of employment. All staff are interviewed by a panel of managers and the interview records were available for inspection. The Manager and staff on duty all stated that the team worked very well together complimenting each others skills. The Manager delegates different responsibilities and tasks to individuals and the staff team appear to relish this. The Manager spoke about the different skills of different members of the team and how these were utilised to improve the environment, care planning, procedures, health and safety, record keeping, communication with service users and activities. The staff on duty reported that they really enjoyed working with such a diverse range of needs and how they had learnt new skills and developed their own practice to support people to meet different needs. Staff on duty reported that they had regular supervision meetings and annual appraisals with the Manager. They reported that they were well supported. Regular staff meetings are held and minuted. These indicate that all staff are able to contribute and take it in turns to chair and minute take. There are recorded handovers of information between each shift, which include checks on money and health and safety. The staff team have worked together to produce their own team plan based on the service and organisation’s objectives and the needs of the service user group. There is a wide range of training available for staff to participate in. The staff on duty reported that their training needs were met and that they were able to request specific training. On the day of the inspection one member of staff was participating in food hygiene training. Training records indicated that each staff member had undertaken a range of training. Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40 & 42 The service is appropriately managed by an experienced and qualified person who works closely with the team. The management approach is open and inclusive and allows for individual service users and staff members to use their talents and skills for the benefit of the service. Records required by Regulation are in place. Appropriate checks are made to maintain good health and safety throughout the home. EVIDENCE: The Manager has worked at the home for five years, and has been in her current post since October 2003. She has been registered with the Commission for Social Care Inspection. The Manager has consistently demonstrated an in depth awareness of the home and the needs of service users. She discussed a comprehensive range of plans for the development of Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 Page 22 the service and demonstrated how she had progressed in achieving these plans. The Manager has just completed her NVQ Level 4 and is undertaking her NVQ Assessors award. The Manager works alongside the staff team and clearly has a good relationship with them. The Deputy Manager and staff on duty spoke positively about her and the support that they receive. The management approach is open and inclusive and the staff team are able to contribute both with ideas and by developing new systems and procedures. Staff meetings indicate open discussion. There is excellent consultation with service users and their representatives through individual and group meetings. Both the Manager and Deputy Manager repeatedly complimented the hard work of individual staff members and the team as a whole and were keen to inform the Inspector about individual achievements of all team members. The Office has been reorganised and a number of new filing systems and records have been introduced or are being developed. There are appropriate procedures for quality assurance and monitoring. The Quality Assurance Manager visits the home monthly to conduct and unannounced inspection of the service. Reports of these inspections are forwarded to the Commission for Social Care Inspection. The staff team have developed a plan for the year and aims and objectives for the service. There is a strong focus on service user consultation and involvement and various plans to enhance this have already been implemented. The implementation of these aims and objectives is monitored on a regular basis through a series of performance indicators developed by the team. There are appropriate checks on health and safety and fire safety. These are recorded. Service users participate in these checks and staff report that they have a good understanding of these issues. Regular fire drills are held and recorded. The Environmental Health Office visited the home shortly before the inspection and was satisfied with the standard of hygiene at the home. They recommended that a hazard analysis is produced for the kitchen. Following guidance, one member of staff has developed a user friendly hazard analysis designed to inform service users about safety issues. This piece of work is very good. Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 4 3 4 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 4 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Egerton Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 4 3 3 x 3 x G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Egerton Road G54-G04 S30462 Egerton Rd V242825200905 Stage4.doc Version 1.30 Page 25 Commission for Social Care Inspection Ground Floor 41-47 Hartfield Road Wimbledon SW19 3RG 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. 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