Inspection on 23/08/06 for 28 Pasley Street

This inspection was carried out on 23rd August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

28 Pasley Street 10/07/07

28 Pasley Street 28/09/05

28 Pasley Street 20/04/05

28 Pasley Street 04/11/04

28 Pasley Street 29/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 28 Pasley Street Stoke Plymouth Devon PL2 1DP Lead Inspector Brendan Hannon Unannounced Inspection 23rd August 2006 9:30 28 Pasley Street DS0000003507.V291922.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 28 Pasley Street DS0000003507.V291922.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. 28 Pasley Street DS0000003507.V291922.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 28 Pasley Street Address Stoke Plymouth Devon PL2 1DP 01752 561459 01752 561459 headoffice@durnford.org Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Durnford Society Limited Ms Michelle Durrant Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (9) of places 28 Pasley Street DS0000003507.V291922.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age 18yrs Date of last inspection 28th September 2005 Brief Description of the Service: The home is located in two combined terraced houses, on the end of a terraced street, in the Stoke area of central Plymouth. A full range of amenities and facilities are within walking distance though, the home has its own vehicle. The home can accommodate up to nine service users over three floors. The home is in an unusual layout being entered on the ground level at the front but then with stairs both descending to accommodation in the lower ground floor level and ascending to accommodation on the first floor level. There are no residents bedrooms on the ground floor at present. There are three communal bathrooms and three communal showers. There are no shared rooms and due to the age of the building all the ceilings are reasonably high giving an additional feeling of space in the home. There are two communal lounges, a kitchen diner and another dining area off one of the communal lounges. There is a large area of patios and parking space to the rear of the building. This can be accessed either from the lane to the rear of the building or from the rear of the lower ground floor. The service offered by the home is for men and women with a learning disability over the age of 18 and perhaps beyond the age of 65. The home would have difficulty supporting residents with significant mobility difficulties. The present group of residents has a mixed range of ages and abilities. The average fee charged by the home is £766 per week. 28 Pasley Street DS0000003507.V291922.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. Preparation for the inspection included analysis of the annual pre inspection questionnaire, the last two inspection reports and contacts with the home over the last 12 months. An inspection plan was developed from this information. The inspector was in the home from 9.30am to 4.30pm on the 23/08/06, and met with the Registered Manager and General Manager on 06/09/06 from 3.00 to 5.00pm to gain further information, and to give feedback on the outcomes of the inspection. In total the Inspector was with the providers for 9.0 hours. The following inspection methods were used. The care of three residents was tracked during the inspection. The inspector spent time with all of the residents during the initial site visit. Residents in the home were also formally surveyed and one responded positively using the questionnaire provided. The General Manager, and the leading staff member on shift were spoken with at length on23/08/06. One of the three care staff on duty on the 23/08/06 was individually interviewed, and three staff personnel and training files were sampled during the inspection. The inspector comprehensively toured the building. Residents’ relatives were sent questionnaires by post and six of the seven relatives/friends surveyed responded. The commissioning Local Authority for the majority of the residents, Plymouth Social Services, was surveyed but did not respond. All areas of documentation in the home were inspected to evidence compliance with the National Minimum Standards. Documents inspected included assessments of residents’ needs and their care plans, various records, including medication administration records, staff/employment records, and health and safety records. Some policies and procedures were also inspected. All information gathered during the inspection was considered in the writing of this report. What the service does well: The house is comfortable, cosy and very clean. There is plenty of good food. Residents have enough things to do to be happy. There are always enough staff to help. The resident’s get all the help they need. Each resident can have their room just as they want it. 28 Pasley Street DS0000003507.V291922.R01.S.doc Version 5.2 Page 6 The staff know how to help people and the staff do their best. If a resident has a problem it is easy to get help. The staff make sure that if someone is sick they will get help from a doctor. The staff are safe to be with. If you want to live there the staff will tell you about what it is like. The staff are good at helping people to move in and be happy. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 28 Pasley Street DS0000003507.V291922.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 28 Pasley Street DS0000003507.V291922.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides enough information about the service to allow a potential new resident, with support from their supporters, to make an informed decision to use the service. EVIDENCE: Both the Service Users Guide (SUG) and the homes Statement Of Purpose were available. Both these documents have been updated to take account of the changes of personnel at the home. This information enables potential new residents and their supporters to understand the service provided by the home. The home was advised to develop a new format for the SUG to make information about the home more accessible to most potential new residents. There is presently enough information provided by the service to allow a prospective resident, with the help of their supporters, to make an informed choice whether or not to use the service. In more recently admitted residents files there was information received by the home from care management before the resident’s admission. A recently admitted resident had visited the home for visits and for one overnight stay before admission. This person was already known to the service as he moved to 28 Pasley St. from another of the Durnford Society care homes. There was a record in his daily diary of his initial visits to Pasley Street and his successful settling in at his new home. A written pre admission assessment for this prospective resident had not been carried out for admission to 28 Pasley St. The Registered Manager is advised to carry out a pre admission assessment of 28 Pasley Street DS0000003507.V291922.R01.S.doc Version 5.2 Page 9 all prospective residents, because all the services provided by the organisation are different, and in order to demonstrate that the service delivered by 28 Pasley St. is appropriate to meet the prospective residents needs. 28 Pasley Street has successfully managed the admission of new residents. Through policy and records there was good evidence to show that new residents’ needs are being met by the service. 28 Pasley Street DS0000003507.V291922.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Good quality care is being delivered. However assessments of residents’ needs, their care plans and risk assessments should be more comprehensive, detailed and up to date to support consistent planned care. EVIDENCE: Resident’s care plans were sampled. There is a good Durnford Society care plan and risk assessment formats available. All the residents’ files had a care plan. Some care plans had not been reviewed for some time, leading to some information being inaccurate. All residents should have a comprehensive and detailed care plan so that the staff can be effectively directed to meet the resident’s identified needs. Progress has been made in this area since the last inspection but there continues to be some work to do on this issue. Some residents’ files did not have all the individual risk assessments necessary so that all the managed risks are comprehensively documented. All the risks and agreed restrictions affecting the individual resident were not identified. In order to protect the resident effectively written risk assessments should identify all the risks and agreed restrictions affecting the resident and the measures in place to reduce these risks to an acceptable level. 28 Pasley Street DS0000003507.V291922.R01.S.doc Version 5.2 Page 11 Where residents have agreed to restrictions of facilities or of choice, in order to maximise the resident’s quality of life, these issues should be documented either in care planning or in risk assessments. Examples of this would be not using a bedroom door key through by the resident’s choice, or the need to be escorted whenever the resident leaves the home in order to ensure their safety. Adequate care planning and risk assessment will help residents’ care to be delivered in a planned and consistent manner and will further improve the residents’ quality of life. There was considerable evidence of the home actively seeking to empower the residents to a more involved and independent lifestyle. Examples of this included the use of bedroom door keys, a photo board to indicate which staff were on, and would be coming on duty, the use of a symbol based daily planner in one residents room and the use of laminated pictures of different meals to enable residents to make food choices. Further evidence of the residents’ active lifestyles was available in the individual resident daily diaries. Entries showed residents being empowered to help to make their own beds and to participate in a range of kitchen activity. Residents, who are enabled to participate in their home and are empowered, have more control over their daily lives. 28 Pasley Street DS0000003507.V291922.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ have enough appropriate activities to ensure a good quality of life. Residents’ receive varied, good food. EVIDENCE: Information from the new resident daily diaries, supported by information directly from the staff on duty, described some of the activity enjoyed by the residents. Activity in the community included work placements, art classes, music classes, swimming, social clubs, the theatre, shopping, lunches in town, and visiting friends. Activity is also supported within the home including sewing, DVD films, music, singing and dancing, cooking, aromatherapy, hand massage and nail painting. All the residents’ information sampled showed individualised and varied activity being enjoyed by the residents both in the community and in their home. Two of the six relatives who responded to the survey of residents’ relatives, commented that they would like more information from the home on the progress of their relative. The inspector advised the home to establish regular contact from the home to relatives about their specific relative’s progress. 28 Pasley Street DS0000003507.V291922.R01.S.doc Version 5.2 Page 13 An accurate record of residents’ activity and experience of the service was contained in the residents’ daily diaries. This information helps the review of care planning and risk assessment. The quality of residents’ activity was accurately detailed in care plans. It could be seen from the menu plans, food delivery records and the various stocks of food and drink in the large fridge freezer, that residents are supplied with enough, good quality food. A record of the food delivered to the residents is in place and shows that the residents are being provided with a healthy and varied diet. The menu plan for the week is devised with consideration for the residents’ food preferences and following discussion with the residents. This discussion is supported with the use of pictures of the meals available. A main weekly household shopping is done at a supermarket by a group of 4 to 5 residents and staff. Residents agree to participate in this shopping. Residents receive enough varied, good food and they also participate in the choice, purchase, and as appropriate preparation, of their food. 28 Pasley Street DS0000003507.V291922.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ personal care needs are met. Residents are well supported to access health services. Medication is managed adequately in the home. EVIDENCE: All the residents present in the home were seen and there was no observable evidence of any personal care issue not being met. Chart recording of residents’ weights was seen. A sample of residents’ records showed appointments with psychiatric health, learning disability nursing, physiotherapy, GP, chiropodist, optician and dental health services. During the inspection care staff and the General Manager were called upon to assist a resident in a medical emergency. This they did in a calm and professional manner, finally escorting the resident to hospital. The specialist in-patient link nurse was contacted as part of accessing the acute health services. These records and the observed care being delivered showed that residents’ health and personal care is being supported. The home uses a monitored dosage blister pack system for medication administration. Medication administration records for this system were seen. A complete set of medication policy and procedure was seen. There had been some confusion with signing for prescribed medication, particularly with creams, and as result some medication signing was missing. There is a 28 Pasley Street DS0000003507.V291922.R01.S.doc Version 5.2 Page 15 medication profile in each resident’s file But some needed to be updated to be completely accurate. The medication storage cabinet is large enough to hold all the residents medication securely and was relatively tidy. Residents’ health and stability is maintained by adequately managed and administered medication. 28 Pasley Street DS0000003507.V291922.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The welfare of the residents is protected by thorough adult protection and complaints procedures. EVIDENCE: There is an adequate new complaints procedure but this was not displayed in a public place. The new complaints procedure leaflet has been produced in Widget symbols and simple English. This leaflet is attached to the Service Users Guide. There has been one complaint made to the home during the past twelve months concerning noise levels heard outside the home. No residents raised any complaints during the inspection process. Six relatives/ friends made comments as part of the inspection process. These were all generally positive. However one comment was made regarding staff turnover and two about communication from the home to relatives. These issues are addressed within the lifestyle section and the staffing section of this report. The home has all the appropriate anti abuse policies and procedures in place. The staff have received anti abuse training both through the Learning Disability Award Framework (LDAF) induction training and through specific anti abuse training. 28 Pasley Street DS0000003507.V291922.R01.S.doc Version 5.2 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 the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit from a homely, comfortable, clean and well maintained building. EVIDENCE: The home was toured during the inspection and no significant repairs were noted. The quality of the living environment and the standard of decoration in the home were very good. The home was very clean, hygienic and odour free. This unannounced inspection found the bathrooms, toilets, kitchen and laundry exceptionally clean and well maintained. Appropriate laundry facilities are in place to control the spread of infection. Standard 30 has been exceeded and the service is commended for cleanliness and hygiene within the home. In recent years improvements have been made to address the increased physical disability needs of the residents. Physically adapted bathrooms and toilets have been developed in the home. All the bathrooms and toilets are fitted with override type locks that can be locked from the inside to give privacy’ but can also be opened from the outside in the event of an emergency. The bathrooms had been decorated to make them feel more domestic in character. Some useful devices have been installed such as motion sensors in some toilets/ bathrooms to turn the light on without the need for 28 Pasley Street DS0000003507.V291922.R01.S.doc Version 5.2 Page 18 light switches. All the bedrooms had been decorated and personalised to meet the taste of the resident using them. All the bedrooms are fitted with appropriate locks. Some of the residents choose to use these locks and others do not. New carpet has been fitted throughout the ground floor areas of the home both to maintain the quality of the living environment but also to address the noise issues raised by the complainant. The organisation has provided the resources to maintain the décor in the home to a high standard. Furnishings and fittings were of good quality. A good quality living environment will meet both the residents’ physical and emotional needs. 28 Pasley Street DS0000003507.V291922.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by enough, competent checked and trained staff. EVIDENCE: Due to a combination of a health emergency involving a resident, none of the home management being on duty, and the presence of a CSCI inspector, the day of the site visit (23/08/06) was very demanding for the staff on duty. The three staff on duty coped very well with the unusual circumstances and pressures placed on them. They demonstrated a high degree of professionalism in meeting the needs of the residents both inside and outside the home during the day. One of the relatives who responded to the relatives survey noted the recent high turnover of staff, and that it is important to maintain continuity of staff in order to promote residents relationships, consistency of care delivery and trust. The home has had approximately 50 staff turnover in the past year. The Registered Manager is confident that staff turnover will now return to normal following this unusual period. She also stated that a new stable staff team has been formed through the recruitment of the new staff. The Registered Manager stated that the staffing level is adequate to meet the needs of the residents. There are often three staff on duty in the morning, 28 Pasley Street DS0000003507.V291922.R01.S.doc Version 5.2 Page 20 including management and additional staff to support residents on specific activities. The rota record showed that there were three staff on duty on seven of the last fourteen days. This staffing level usually reduces to two after 4.00pm until 8.00pm when night staffing begins. At night there is one waking staff and one sleeping in staff on duty. The daytime minimum staffing level is two staff at all times. The Registered Manager and General Manager stated that, although the staffing level in the home is adequate to meet the needs of the residents at this time, the staffing level is kept under review. A thorough training programme is run by the organisation to ensure that the level of qualification of the staff in the home is maintained. At present 50 of the care staff are qualified to NVQ2 in Care or above. The organisation is also actively training staff who are new to work with this client group in the Learning Disability Award Framework (LDAF), which is designed to give care staff specific skills to work with people with a learning disability. This training enables staff to meet residents’ needs soon after beginning work with the organisation. Basic Health and Safety training and additional training was also checked and was complete demonstrating the organisations support for a trained competent work force who are safe and can meet the residents needs. A sample of staff personnel records were checked and these showed that recruitment procedures to protect vulnerable adults are in order. All staff had had appropriate Protection of Vulnerable Adult (POVA) register and Criminal Records Bureau (CRB) checks. These checks help to ensure that the residents are kept safe. 28 Pasley Street DS0000003507.V291922.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is effective, ensuring that residents needs continue to be met. EVIDENCE: The Registered Manager, Michelle Durrant, came into post at the beginning of April 2005. She has both the Registered Managers Award and the NVQ4 in Care qualifications. Following initial progress after her arrival at the home the rate of development and improvement at the service has slowed. The Registered Manager intends to continue to follow the homes programme of improvement including dealing with the recommendations made in this report. The management and staff were seen to be working well together during a period of pressure for the service. Good working relationships amongst the staff team is promoting good quality support for the residents. The organisation has developed a Quality Assurance (QA) system. A quality assurance round was carried out in December 2005 till January 2006. Feedback information has been obtained from the residents and stakeholders 28 Pasley Street DS0000003507.V291922.R01.S.doc Version 5.2 Page 22 for the service. The Registered Manager agreed that the present system of written questionnaires was not well suited to the communication abilities of the residents. The Registered Manager said that the shortcomings of the QA system have been recognised and that the organisation’s home managers group will reconsider the present system. The potential of a spoken method of questions and answers was discussed. The difficulties in communication prevent the residents engaging effectively in the process used to improve the quality of their service. The written QA outcomes for the home were available but had been combined for all the services in the organisation. It was advised that conclusions from the QA round should be separated to enable the public to identify the progress made by each care home. A reasonable attempt has been made to obtain the views of the residents and stakeholders about the service. The records seen during the inspection were generally good, such as the accident record, and residents’ daily diaries. These records assist management in monitoring the delivery of care to the residents at the home. Receipt of Regulation 26 monthly reports for the home from the organisation has been sporadic, though a report has been received for July 2006. The organisational management for the home is advised that a report should be received by the CSCI for each month. Health and safety is generally well managed in the home though, as noted under standard 9, a number of new risk assessments need to be written both for the residents individually and for the facilities in the home, to demonstrate that the risks affecting residents have been assessed and are being maintained at an acceptable level. The Registered Manager stated that valves to control hot water temperature have been fitted to all the hot water taps in the home except those in the kitchen. The Registered Manager stated that most radiators have been covered and the Registered Manager stated that none of the residents were at risk from an uncovered radiator. All uncovered radiators that have not been covered should be individually documented in risk assessment. The Registered Manager stated that all windows openings above a significant drop have been restricted to a space adequate for ventilation only. The fire check and training records were seen and these were of an acceptable standard. The accident records were also checked and none of the accidents documented gave cause for concern. Good management of health and safety protects the welfare of the residents. 28 Pasley Street DS0000003507.V291922.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 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 4 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 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 2 X 3 3 3 3 3 3 X 28 Pasley Street DS0000003507.V291922.R01.S.doc Version 5.2 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. 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 YA6 2 YA9 Refer to Standard Good Practice Recommendations All the residents should have a care plan which is comprehensive and detailed. All residents’ needs should be identified and how staff are to meet these needs. Each resident should have comprehensive and detailed individual risk assessments. These assessments should include all restrictions of choice or personal freedom agreed to be in the resident’s best interests. All prescribed medications being administered by the home should be signed for comprehensively. Medication profiles should be kept up to date. 3 YA6 28 Pasley Street DS0000003507.V291922.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. Extracts may not be used or reproduced without the express permission of CSCI 28 Pasley Street DS0000003507.V291922.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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