Inspection on 10/07/07 for 27 Larchwood Close

This inspection was carried out on 10th July 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

27 Larchwood Close 05/10/06

27 Larchwood Close 24/01/06

27 Larchwood Close 30/08/05

27 Larchwood Close 05/01/05

27 Larchwood Close 10/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 27 Larchwood Close Banstead Surrey SM7 1HE Lead Inspector Lisa Johnson Unannounced Inspection 10th July 2007 09:25 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 27 Larchwood Close DS0000013471.V342281.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. 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 27 Larchwood Close Address Banstead Surrey SM7 1HE 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) 01737 370115 www.mencap.org.uk Royal Mencap Society Mr Dennis Ronald Shattell Care Home 7 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0), Physical disability (0) of places 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2006 Brief Description of the Service: Larchwood (27) is a large detached property located in a residential area in Banstead, Surrey and is registered with the Commission for Social Care Inspection as a care home providing personal care for six people with a learning disability. Accommodation is on two floors accessed by stairs and comprises of six single bedrooms, a lounge, dining area, kitchen, utility room, office, shower rooms and a bathroom. The home has a large garden to the rear of the property, which is easily accessible, and private parking is available to the front of the property. The weekly fees range from £ 446.92- £637.40. 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The visit was unannounced and took place over seven and half-hours commencing at nine twenty five am and finishing at five pm. The visit was carried out by Mrs. L Johnson Regulation Inspector. The inspector spoke to four people who live in the home to gain their views on the care provided and four surveys were also received. Two surveys were received from relatives and one from a health care professional. Due to communication difficulties experienced by some individuals their direct views about their care could not be obtained. Therefore observations of interactions and service user responses through non- verbal communication have been reflected in this report. A full tour of the premises took place. Information was examined which was provided by the manager with the Annual Quality Assurance Assessment (AQAA) prior to this visit. Care plans and policies and procedures were sampled. The inspector spoke to two members of staff. The inspector would like to thank the people living in the service and staff for their time, assistance and hospitality during this inspection. What the service does well: The service provides a friendly, welcoming and homely atmosphere. Good relationships were observed between people using the service and staff who were participating in activities together including shopping and meal preparation. People using the service have detailed care plans in place supported by risk assessments. People using the service are supported to access and participate in a varied range of activities. One person said, “I work in McDonalds” and another individual said that he likes doing art. During this visit people were seen assisting preparing the evening meal and making themselves snacks and sandwiches. One person said, “I do my cleaning and my washing “. 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: It is recommended that the home maintain a copy of the assessment which is to be conducted for any future prospective individuals moving into the service with their records. Further improvement is needed to ensure that care plan reviews are updated. Individual care plans must be signed by each person and/or their representative ensuring their agreement to their care plan. Improvement is needed in some areas of medication administration practices ensuring the wellbeing and safety of people. 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 7 Due to the absence of the registered manager at this visit the staff recruitment and training files could not be viewed. It is required that arrangements are made for access to the personal files for viewing at the next site visit to ensure that service users are protected by the home’s policies and procedures. It was recommended that the staffing levels be reviewed at weekends ensuring that the needs of people living in the home are met. 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. 27 Larchwood Close DS0000013471.V342281.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 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People using the service receive good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The needs of people are assessed prior to admission to the home. EVIDENCE: There have been no admissions in the home for three years. The company has a detailed admissions policy in place, which covers all aspects of care including culture and diversity. During this visit three-individuals files were examined. Information provided by the manager in the Annual Quality Assurance Assessment stated that community care assessment assessments are obtained from placing authorities and that the manager would meet prospective individuals to carry out their own assessment. It was recommended that copies of assessments carried out for any prospective people moving into the service should be maintained with individuals records ensuring that the service is able to meet their needs. 27 Larchwood Close DS0000013471.V342281.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 & 9 People using the service receive good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service are provided with an individual care plan, which records their individual needs and goals. People are supported to make decisions about their lives with assistance and they are supported to take risks as part of an independent lifestyle. EVIDENCE: Three individual care plans were viewed. Each care plan contained a pen portrait and personal profile. Plans were based on personal, health, emotional, communication and social needs. Further improvement is still required in ensuring that plans are regularly reviewed, which the manager has identified as an area for improvement. However some progress has been made with the manager introducing monthly one to one meetings with individuals and their key workers and evidence of this was viewed. Two individuals spoken with said that they have meetings to discuss how things are going and things that they would like to do. Two members of staff spoken with were aware of the care plans which they are involved with reviewing and demonstrated knowledge and understanding of the support needs of each individual. Two relatives surveyed stated that the home informs them of any changes in their 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 11 relatives needs or care, although improvement is required ensuring that people living in the service and/or their relatives should sign their care plan ensuring their agreement and where individuals are unable to sign this should be also recorded in the care plan. Service users are consulted and supported to make decisions about their lives with assistance where required. The home holds regular service user meetings. One individual spoken with said he wished to ride a bike, which has been responded to by their key worker who has arranged cycling lessons. Two individuals have been attending interviewing training so that they can participate in the staff recruitment process, which was confirmed by one individual who said, “I am going to be interviewing staff soon”. The service will be changing to supported living and it was evident that people living in the home were aware of this process which one individual told the inspector about. People living in the home are currently being supported by an external advocacy agency to support them through this change. The support that individuals require with their finances was clearly documented in their care plan. Records were sampled for two individuals, which were appropriately recorded and balances were correct Relative’s surveys and a health care professional survey received indicated that the service meets the diverse needs of people using the service. Comprehensive risk assessments were included in each individual’s plan including for example using the kettle and the iron, bathing and showering and emotional support, which included management guidelines. Risk assessments are brought to the attention of staff and a read and sign system was in place, although the home is advised to ensure that all risk plans are kept up to date, as there were occasional gaps. 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 & 17 People using the service receive good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are provided with a range of appropriate activities and engage in a range of leisure activities. People are supported to take part in the local community and their rights and responsibilities are respected. The home is able to demonstrate that people who use the service are provided with a well-balanced and nutritious diet. EVIDENCE: The home supports people to access varied recreational and social activities that meet their needs and preferences. Care plans sampled included details of the activities that individuals attend. It was evident that people living in the service are supported to be as independent as possible. One individual said, “I work in McDonalds on a Saturday and I go by bus”. Another individual said that he likes doing “art”. Some people attend day services, visit the pub, attend pottery, going shopping, visiting the library, visiting the cinema and attending social clubs. The manager provided information in the Annual Quality Assurance Assessment that one person is being supported to attend part-time employment and another person attends college. People living in the 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 13 service are supported to go away on holidays, which was confirmed by one individual who said, “I am going to the Isle of Wight”. The religious beliefs and faith of people are respected and where people wished to attend church this was recorded in their care plan People living in the home maintain links with their family and friends and during this visit one person was returning after a home visit. People spoken with during this visit told the inspector about their families and friends and staff stated that they support individuals with writing letters and a telephone is available for people to use to maintain contact. One individual showed the inspector the photographs that he kept in his bedroom of his family. Records of family contact are maintained. During this visit good interaction was observed between people living in the home and staff who were participating in home activities and routines together including shopping and meal preparation. One person stated that he had his own key for the front door and his bedroom. There were no restrictions and service users were observed to be in the kitchen helping themselves to drinks and involved with meal preparation. One individual went out shopping with a member of staff he smiled and nodded his head to express his enjoyment. One person stated, “I do my cleaning and my washing” and another individual said that staff maintain his privacy by knocking on his door. Menus are planned on weekly bases, which were seen on display, and people using the service are consulted and involved in the planning which was confirmed by two individuals spoken with. Picture cards of a range of meals are used to assist individuals who have communication difficulties to assist them to make choices about their preferences. Meals provided were nutritious and well balanced. The main meal is served in the evening, which some individuals had the opportunity to help prepare. Three people spoken with said they liked the food in the home and one person said that they could have their favourite meal “fish and chips”. 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People using the service receive good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that people using the service receive personal support in the way they prefer and that their physical and health needs are met. Some matters were identified that need improvement ensuring people using the service are protected by the home’s medication administration procedures. EVIDENCE: Each person’s plan recorded their personal and health needs and how these were to be supported. Each individual’s preferred choice of gender of staff support was recorded in their care plan and their likes and dislikes were documented. Staff were observed to respect and maintain individuals privacy when carrying out personal care by keeping doors shut. One person’s care plan stated that this individual requires blood pressure monitoring. Records were maintained of appointments for these checks. Another individual has had a past health matter which requires annual monitoring and records confirm attendance at these appointments. It was evident that all routine health appointments were recorded including chiropody and visits to the dentist. People are registered with a local GP and links are maintained with the learning disability community team. 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 15 Two relatives surveyed state that the home always gives the care and support to their relative. Comments received from a health care professional included, “The clients are looked after well and the staff are very prompt in seeking advice and treatment and follow this well”. The home’s medication administration systems were examined. The home has a company medication and administration policy. Photographs of individuals were available with their medication administration record. Medication was stored appropriately. It was observed that one person was receiving cod liver capsules, which had been hand transcribed by staff, which was not dated or signed. During this visit this matter was attended to. Improvement is also needed in respect of the practice of secondary dispensing of medication, which was observed, although there was a system in place for safe checking, there was no completed risk assessment, therefore it was required that this must be completed and advice sought from the local pharmacist. The home must also maintain a list of staff that are trained and authorised to administer medication and an authorised record of homely medication remedies that can be administered ensuring the health, safety and welfare of people using the service. 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People using the service receive good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The views of people are listened to and acted upon and they are protected from abuse. EVIDENCE: There is a complaints procedure in place. A copy of the procedure was seen on display in the hallway, although the manager is advised to update the contact details of the Commission for Social Care Inspection. No complaints have been received by the Commission since the previous visit. Information received with the Annual Quality Assurance Questionnaire recorded that the home has not received any complaint. A complaints folder was seen on display, which was viewed containing relevant documentation to record any information, should a complaint or concern arise. Two people spoken with during this visit said that they would know who to speak to if they wished to raise a concern. Responses included. “The manager” and “key worker”. Four people surveyed said that staff listen and act on what they say. Two relatives surveys received indicated that they are aware of how to make a complaint and that the home responds appropriately. During this visit the inspector spoke with two relatives who were visiting who stated that they were happy with the home and a health care professional commented, “Caring staff “. During this visit one issue was brought to the attention of the inspector, which was discussed with the company’s area manager in the absence of the registered manager who responded to this matter promptly. The home was in the possession of Surrey multi- agency safeguarding adults from abuse procedures and the home had its own procedure. The manager 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 17 was unavailable during this visit to view staff training records although the manager provided information that all staff have now received appropriate training, which was confirmed by three members of staff spoken with. Two members of staff were clear in their responses as to their responsibilities and actions that they would take should they ever witness any abuse. The inspector also spoke with the company’s area manager who said that the manager had completed the local authority safeguarding adults from abuse training. To further promote equality and diversity the manager provided information that the service is planning to support one individual to become a trainer for Learning Disability Abuse. 27 Larchwood Close DS0000013471.V342281.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 & 30 People using the service receive good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service live in a safe, well-maintained and clean environment. EVIDENCE: During this visit a tour of the home was conducted. There is an open plan kitchen/dining room and a separate lounge, which was comfortable and well maintained. There is an accessible garden to the rear of the property, which needs some maintenance, as some areas were overgrown. There is a walk in shower on the ground floor, which meets the needs of individuals with mobility difficulties. Bedrooms viewed during this visit were decorated and furnished to a good standard and were personalised by individuals interests and preferences. The home was cleaned to a good standard and hygienic throughout and it was observed that the required work to the laundry room was near to completion ensuring it is impermeable to the spread of infection. An infection control procedure in place and a copy of the Department of Health guidance were observed in the manager’s office. 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People using the service receive adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty were adequate to meet the needs of people using the service. One matter needs attention to ensure that people are protected by the home’s recruitment policies and procedures. People using the service are in the safe hands of the staff that were competent and trained to do their jobs. EVIDENCE: During his visit there were two members of staff on duty. One person was employed on Mencap’s bank system and had worked in the home for over two years. The manager has provided information that there is an ongoing recruitment programme and there have been some difficulties in recruiting staff although the company has its own bank system and the inspector was informed that the home does not use agency staff. Since the previous visit the home has recruited a new male member of staff to increase the gender mix of the staff team. During discussion with staff it was clear that staff were aware of their responsibilities with staff now being provided with designated tasks and they receive monthly formal supervision. 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 20 Two members of staff are provided during the day and sometimes three when the manager is on duty. At nighttime a sleep in staff is provided and an on call system is in operation if support is required after hours. Staff informed the inspector that this had only been required on one occasion. Staff felt that in general that staffing levels were sufficient, although it has been recommended that the staffing levels are reviewed at weekends in view of the number of activities that people attend some of whom require support. Photographs of members of staff were on display to assist people in identifying which staff were on duty. The registered manager was unavailable during this visit therefore the training records and recruitment files of staff could not be accessed to fully verify information, therefore a requirement was made that arrangements be made for the key to be made accessible to view documentation. Information received from the manager stated that the company provides training to staff including first aid, moving and handling, understanding learning disabilities and mental health. Fifty percent of care staff have obtained National Vocational Qualifications. New staff undergo the Learning Disabilities Award Framework (LDAF) induction and foundation training which was confirmed by one member of staff who had commenced employment eight months ago who said that the company provides good training and told the inspector about some of the training he has attended including safeguarding adults from abuse, makaton, healthy eating, medication administration and fire awareness. The other member of staff on duty stated that she was completing National Vocational Qualification (Level 3) and had completed a number of training courses including first aid, safeguarding adults, manual handling, fire safety, diabetes and epilepsy. Surveys received from relatives said that staff have the right skills and experience to look after people. The company has a recruitment and equal opportunities policy in place. The most recent member of staff stated that he had attended an interview prior to commencing employment, had supplied two references and had undergone a POVA First check and that he had worked under supervision until the full Criminal Records Bureau check had been obtained. Both members of staff confirmed that they had been made aware of the General Social Care Code of Conduct with one member of staff showing this document to the inspector. 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People using the service receive good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service benefit from a home, which is well run, and in their best interests and their safety and welfare are protected. EVIDENCE: Since the previous visit the manager has now registered with the Commission for Social Care Inspection. Information provided by the manager states that he holds a National Vocational Qualification (level 4) in management and is commencing the Registered Managers Award in September 2007. Two members of staff spoken with said that they felt supported by the management structure and that there was good communication with regular meetings taking place. The minutes of these meetings were viewed during this visit. The inspector was informed that the company has recently sent out surveys to gain feedback from relatives and stakeholders about the care provided. 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 22 Surveys are to be sent again shortly to people using the service. The home is advised to maintain the outcome of these surveys in the home to be made available for viewing. Monthly quality visits are conducted with the reports being maintained in the home. These reports were observed to be well structured and detailed. The home conducts meetings with people using the service on a regular basis and the outcomes were recorded. The company provides a range of policies and procedures, which are going through a process of being updated. During this visit substances hazardous to health (COSHH) were stored securely and appropriately. Health and safety checks are completed and recorded. Records were maintained of water temperature checking. Fire records were appropriately maintained confirming that regular fire alarm checks, fire drills are conducted. Information provided in the Annual Quality Assurance Assessment indicates that systems are in place for routine service and maintenance arrangements for the environment. . 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 24 Yes 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 YA6 Regulation 15 (2) (b) Requirement Timescale for action 10/09/07 2 YA6 15(2)(c) 4 5 YA20 YA34 13(2) 19(1-5) Schedule2 The registered person must ensure all care plans are reviewed on a regular basis. (Previous requirement 06/10/06 not met) The service must ensure that 10/09/07 service users and/or their representatives sign to agree to their individual plan. Where this is not possible this should also be recorded in the care plan. The home must maintain an 20/07/07 authorised list of homely medication. Arrangements must be put in 10/08/07 place for the key to access the staff personnel files. 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 1 Refer to Standard YA2 YA33 Good Practice Recommendations It is recommended that the home maintain a copy of the assessment which is to be conducted for any future prospective individuals moving into the service. It is recommended that the staffing levels are reviewed at the weekends. 27 Larchwood Close DS0000013471.V342281.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 - 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!