Inspection on 20/02/07 for 26 Shakespeare Road

This inspection was carried out on 20th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

26 Shakespeare Road 12/01/10

26 Shakespeare Road 23/02/09

26 Shakespeare Road 04/08/07

26 Shakespeare Road 08/02/06

26 Shakespeare Road 16/09/05

26 Shakespeare Road 03/02/05

26 Shakespeare Road 20/10/04

26 Shakespeare Road 24/02/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 26 Shakespeare Road Worthing West Sussex BN11 4AS Lead Inspector Mrs D Peel Unannounced Inspection 20th February 2007 09:30 26 Shakespeare Road DS0000014297.V325778.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 Shakespeare Road DS0000014297.V325778.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 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 26 Shakespeare Road Address Worthing West Sussex BN11 4AS 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) 01903 230029 shakespeare@sussexoakleaf.org.uk Sussex Oakleaf Housing Association Limited Mrs Vanessa Brenda Saunders Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 2006 Brief Description of the Service: 26 Shakespeare Road is a care home registered to provide accommodation and personal care for up to eight persons with mental disorders who are between eighteen and sixty five years of age. The registration allows for one of the eight service users to be over the age of sixty-five. The service is provided by The Sussex Oakleaf Housing Association Ltd for whom the Responsible Individual is Mrs Tracey Faraday-Drake. The registered manager in charge of the day-to-day running of the home is Mrs Vanessa Brenda Saunders. The property consists of a large semi-detached house in a residential area of Worthing with local shops and other amenities such as the seafront and beach within easy walking distance. The current fee being charged at the home is £770.60 per week. 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was carried out by Mrs Jan Foley, (regulation manager) Mrs Diane Peel (regulatory inspector) and a pharmacy inspector, Mrs Jeanette Datoo on the 20th February 2007. This was the first key inspection to be carried out at the home since January 2006 when it was considered that the outcomes for service users were of a good standard. The National Minimum Standards assessed on that occasion were found to be met in full or exceeded. During this visit on the 20th February 2007 the intended outcomes for 33 standards were assessed; these included the key standards for care homes providing a service to Young Adults aged 18-65. Prior to the visit the inspectors reviewed the previous two inspection reports detailing the outcomes for service users at the visits carried out in August 2005 and January 2006, a pre-inspection questionnaire returned by the manager of the home, other information gained over the past year from the organisation and information about concerns brought to the attention of the Commission for Social Care Inspection (CSCI) by a visiting professional. The inspectors arrived at 9.30am and met with the member of staff on duty who was later joined by the deputy manager. A tour of the building was undertaken with all communal areas being viewed. Two service users offered to show the inspectors their private accommodation and a third bedroom, which was unoccupied whilst a service user was in hospital was also viewed. During the visit the inspectors examined all eight care plans and records of care to see how the assessed needs of service users were being met. Staff on duty were spoken with to find out their knowledge and understanding of service users needs and how these were being met. Four out of the seven service users at home spoke to the inspectors about different aspects of their lives at the home. What the service does well: The service provides a well-maintained homely environment for services users who have been able to make their private accommodation their own. The property is in keeping with the local community and offers access to local amenities, local transport and support services to suit the lifestyle of service users. All service users have an individual plan of care, which has been developed from an initial assessment of need and then revised to show the changing 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 6 needs and circumstances of each service user. The plans are agreed with service users and address physical and mental health care, trigger factors for staff to alert them to indicators, which may show a change in service users mental health, risk assessments. Service users are supported to take an active role in the day-to-day running of the home with opportunities to make informed decisions about their lives. Systems have been identified to maximise people’s ability to communicate their own chosen way so that they have an important part to play in the home. Service users are protected by effective recruitment procedures, which ensure that all staff have undertaken a thorough selection process. 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 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 26 Shakespeare Road DS0000014297.V325778.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 26 Shakespeare Road DS0000014297.V325778.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): 1,2,3,4,5, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with the information they need to make an informed choice about the home and are encouraged to visit the home before deciding if they want to live at the home. Residents are assessed prior to moving into the home to make sure that the home can meet their needs. There are times when service users needs are not being fully met when bank staff on duty do not have the skills to deliver the services which the home offers to provide. EVIDENCE: The home has a Statement of Purpose and Service Guide, which are regularly updated. The most recent version was provided to the inspectors some weeks prior to the visit to the home. The last person who moved to the home was undertaking a trial period at the home during the last visit in January 2006. 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 10 At this time the assessment records of this person were examined and found to contain a full assessment of needs as well as comprehensive background information. At this visit on the 20th February 2007 an inspector also saw letters in the same persons file confirming that over night stays at the home had been successful and future weekend stays had been planned. There was also a letter, which referred to an “enclosed service users guide” which had been sent to the same prospective service user. Staff spoken with during this visit told the inspectors about the concerns they had about the reduction in staffing levels, which they felt, had resulted in a reduced service level. There had been an occasion when staff who had not been assessed as competent to administer medication, particularly P.R.N medication had been on duty alone and staff spoken with said that on the new rota system bank staff who had not been assessed as competent to administer medication could also be on duty alone . There were also concerns from staff that they could no longer be assured that medical appointments made, would be kept and that there would be little flexibility for social activities for residents who needed accompanying out of the home. A written complaint made by a service user to the manager was also seen. The content implied that sometimes the staff were too busy to take them out and that they were bored. All service users have a licence agreement and these were observed in the care records viewed by the inspectors. 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 11 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. Care planning systems are person centred so that service users know that their assessed needs and changing circumstances will be reflected in their individual plan. Service users are included in decisions made about life in the home and are supported to take risks so that they have opportunities to exercise choice and have a fulfilling life style. EVIDENCE: All eight care records viewed at this visit to the home were comprehensive and included information which staff need to be able to support service users to retain varying levels of independence. The files are divided into sections and include the care plan, physical and mental health care, trigger factors for staff 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 12 to alert them to indicators which may show a change in service users mental health, risk assessments, medical appointments and medication. The care plans had been signed by the majority of residents although it was noted that some plans, which had recently been reviewed with service users, had notes on them indicating that the service users had yet to sign them. Each resident also has a weekly plan of activities including chores which are shared and other individual chores such as changing their bed and cleaning their bedroom assisted by staff. Service users have meeting and there is an agenda for them to add to on the notice board in the hallway. The most recent meeting had been held on the previous Sunday and before that on the 28th January 2007. 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 13 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, 14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users living at the home take part in a variety of activities and have opportunities for personal development so that they feel valued and have opportunities to develop skills. Staff support service users to maintain contact with their families and friends so that they can maintain and develop relationships outside the home. Service users are offered a varied diet and can have alternatives if they wish. EVIDENCE: When the inspectors arrived at 9.30 am one service user was up sat in the lounge and another had already gone out to the shops. The other service users got out of bed at times to suit themselves throughout the morning and came downstairs to help themselves to a drink and breakfast if they wanted it. 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 14 After lunch one resident went out shopping with a volunteer and another resident was heard to remind a member of staff that they wouldn’t be able to attend the Rose Den because they were going to the Doctors. At lunch time one service user was observed to cooking themselves some bacon to eat with toast. At least one service user needed assistance to get their lunch. Information provided by the manager prior to the visit to the home and confirmed by individual service uses and their weekly programme charts showed that the home has created links with various community service which also include mental health specialists such as: The MIND Day Centre, The MIND Drop–in Centre, The Rose Den which is a therapeutic centre for the service users of this and two other mental health projects, The Rowans Day Centre. Within the home residents are encouraged to pursue their own interests and hobbies. There is a computer available along with art materials, board games, TV, Music and Videos. Service users are encouraged to make their own breakfasts and snack lunches with the main meal of the day being prepared for all services users in the evening by staff. On the day of this visit the main meal of the day was already written on a board in the kitchen as Corned beef Ash with an alternative of Quiche and Salad. Menus supplied by the manager showed a varied diet with a vegetarian option being offered each day. 26 Shakespeare Road DS0000014297.V325778.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 adequate. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way that they want so that they can maintain individual levels of independence. A variety of healthcare professionals are involved in maintaining the physical and emotional needs of residents. The arrangements were insufficient, for ensuring that “as required” medicines are available to service users at any time needed EVIDENCE: The levels of support with personal care is identified in each persons care plan and for one person this had resulted in an additional care package purchase from Social Services carers. All residents are registered with GPs and some residents are able to make their own appointments and attend them independently whilst other need support and assistance form staff. 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 16 The Community Mental Health Team provide support and residents have access to such services as dentists, opticians and chiropodists in the local community. There is documented evidence, which records visits to medical professionals such as the dentist, doctor, chiropodist and opticians. A member of staff was observed preparing medicines, with reference to the medication administration record (MAR), which was signed after administration. A staff member said that, if there were urgent problems to deal with at medication time, this might delay giving medicines. The staff member was aware that, on one day, a service user had refused medicines until late morning but that this later time had not been noted on the MAR. It was discussed that if medicines were delayed the actual time of administration should be recorded. To enable service users to self-administer some or all of their medicines, the home has individualised medication guidelines, one of which was dated 28.04.06 and one had no date. It was agreed that medication guidelines should be dated and reviewed. There were lists of permanent staff and bank staff, authorised to give medicines. Four bank staff had not been trained and assessed as competent to give medicines. Staff said that at times, between regular medication rounds, the only staff member on duty had not been trained and assessed to give medicines and in this case trained staff would give regular medicines and assess the need for as required (prn) medicines, before going off duty. The deputy manager said that senior management had been made aware of the lack of staff to administer prn medicines at some times and the situation was being monitored. The deputy manager said that she had recently attended a training course, which included a system for assessing staff handling medicines. Handwritten entries on a MAR, for two medicines, had no indication of who had written these and for one there was no supply available. Staff said they would consult the prescriber and if necessary ensure a supply. It was recommended that handwritten entries on the MAR charts should be dated and signed and if possible include the signature of a witness. The home has a procedure for administration of behaviour changing PRN medicines, which referred staff to indicators and protocols not available. Staff said they would refer to a different guide in care plans. It was agreed that the PRN procedure would be reviewed and discussed that guidelines on PRN medicines for individual service users would inform staff making decisions about administration. Staff said that dates of nurse visits would be noted, but there was no record of administration, when a nurse brings and administers a prescribed injection. The deputy manger agreed to discuss, with the nurses, having a record in the home. 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 17 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 18 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. Arrangements are in place for service users and their families to make complaints if they are not satisfied with something. The registered person has arrangements in place to protect service users from being placed at risk of harm or abuse. EVIDENCE: The home has a complaints procedure, which is include in the Statement of Purpose and Service User Guide and on view on the notice board in the hallway. The record of complaints was viewed and observed to have detailed records of complaints made and how they were investigated. A service user told an inspector that they had had a reason to complain to the manager recently. They said that they “were satisfied that she had taken it seriously and had taken it further to people at Sussex Oakleaf”. Another complaint had been made by a service user, which had yet to be entered in the complaints file but the written complaint was seen by the inspectors and was about staff being too busy to take that person out. 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 19 A copy of the West Sussex Adult Protection procedures is held in the home and available to staff and service users. Information provided by the manager prior to the visit to the home confirmed that the organisation has an adult protection procedure. Discussion with the deputy manager confirmed that all staff have all received training in these procedures and are aware of their responsibilities should they suspect an abusive situation. One adult protection matter has come to the attention of the Commission for Social Care inspection, which has yet to be resolved. 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 20 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): 24,25,26,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 26 Shakespeare Road provides a comfortable clean home for service users to enjoy living in. Service users have their own bedrooms, which they are supported to keep reasonably tidy and clean. EVIDENCE: During this visit to the home the inspectors viewed all communal areas and the private accommodation of two service users who took inspectors to their rooms and one room, which was unoccupied because the service user was in hospital. Communal areas were observed to be clean and tidy. One service user was apologetic about the untidiness of their room and said “the staff helped him clean his room on a Friday”. The other service user was pleased to be able to 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 21 show off their collection of soft toys and newly purchased bedding which they said they had purchased on a recent visit to the shops with a member of staff. All service users have keys to their doors so that they can choose to lock their room when they are unoccupied. 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 22 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): 32,33,34,35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users may not receive the support that they need by a reduction of staffing levels and staff who do not have all the necessary skills to meet their needs. Recruitment procedures safeguard and protect residents at the home. EVIDENCE: The home has a training programme in place, which provides the majority of skills to meet service users needs however there was no evidence that any staff had recently attended any moving and handling training to ensure the safety of themselves and residents who may need assistance at times and fire training records do not demonstrate that all staff have taken part in training and fire evacuation plans. Information provided by the manager prior to the visit to the home reports that 60 of permanent staff have an NVQ qualification and that seven staff hold a First Aid certificate. 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 23 The inspectors were told by staff on duty that there had been a considerable number of staff hours reduced. This was confirmed in information provided by the manager in a pre inspection questionnaire, which reported a reduction of 105 hours per week. It was also recorded in the pre inspection questionnaire that over the last eight weeks there had been a need to use 249 hours of bank staff hours. Staff rotas showed that it had been a regular practice for one member of staff to be working alone in the home for sometimes up to a period of two and three quarters hours. The staff on duty confirmed that the new rota would also include periods of lone working which was a concern to them because there could be periods of time when bank workers who have not been assessed as competent to administer medication could be on their own for an hour and would not be able to provide PRN medication if required. Staff records sampled at this visit to the home were in good order. All records seen included an application form, interview questions and evidence of identity and evidence of CRB and POVA checks. 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 24 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): 37,39,41,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The views of resident’s families and friends are being sought to measure how successful the home is at meeting its aims and objectives and the statement of purpose of the home. Some practices have not promoted and safeguarded the health and safety of residents living at the home EVIDENCE: There has been no change of manager at the home but Mrs Sanders has reduced the number of hours that she works and the deputy manager is also part time. 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 25 Mrs Sunders has the necessary experience and qualification to manage the home. A quality assurance system is in place, which has consulted with residents though surveys. Staff commented that they had asked the organisation to consider making the document more user friendly so that service users could complete it without assistance. There was also evidence that at least one outside professional who has regular contact with service users had returned a consultation questionnaire. Service users meetings are held and a the service users guide lists other methods of consultation with service users as: a locked suggestion box in the communal lounge, a moans, groans and cheers book, kept in the lounge and an annual audit involving residents and other stake holders. The majority of records seen at this visit to the home were informative and had been kept up to date, however there was a lack of records to demonstrate that all staff were being involved in emergency fire procedures it was difficult to see which staff had attended what training. No staff had attended moving and handling training. A requirement has been made that all staff working at the home have moving and handling training to ensure that service users needing some assistance and staff are not been Put at risk. 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 26 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 2 5 3 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 X 28 3 29 x 30 3 STAFFING Standard No Score 31 X 32 1 33 1 34 3 35 1 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X X 1 X 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 27 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 YA3 YA20 Regulation 13.2 Requirement Timescale for action 01/04/07 2 YA33 18.1 (a) (b) (c) 3 YA42 YA32 13.5 4 YA42 YA32 23.4 (d) (e) There must be a member of staff on duty at all times who has been assessed as competent to administer medication to service users so that service users requesting PRN medication have that need met. Staffing levels must be reviewed 01/04/07 on a regular basis to ensure that the social, physical and emotional needs of service users are met. All staff must have moving and 01/05/07 handling training to ensure that residents and staff are not at risk from poor handling methods. All staff must take part in fire 01/04/07 evacuation training so that in event of a fire they know how to respond to the emergency. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000014297.V325778.R01.S.doc Version 5.2 Page 28 26 Shakespeare Road Standard 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 26 Shakespeare Road DS0000014297.V325778.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!