Inspection on 27/07/04 for 287 Dyke Road

Care Homes For Adults (18 ­ 65)287 Dyke RoadHove East Sussex BN3 6PDAnnounced Inspection27th July 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment 287 Dyke Road Address Hove, East Sussex, BN3 6PD Email address info@cmg-corporate.com Name of registered provider(s)/company (if applicable) Care Management Group Limited Name of registered manager (if applicable) Vacant Type of registration Care Home No. of places registered (if applicable) 3 Tel No: 01273 551023 Fax No:Category (ies) of registration, with (number of places) Learning disability (3) Registration number H590002015 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply? Date of last inspectionDate of latest registration certificate 4th May 2004 YES YES 24/02/04 If Yes refer to Part C287 Dyke RoadPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 327th July 2004 10:00 am Mike FlintID Code078436Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionFloss Croissant287 Dyke RoadPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers Agreement287 Dyke RoadPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of 287 Dyke Road. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.287 Dyke RoadPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 287 Dyke Road is one of a group of homes owned by Care Management Group Limited (CMG). The home has operated since 1985, providing residential and social care to three service users with learning disabilities and multiple health care needs. Since the Care Management Group took ownership in May 2004, the home has remained unoccupied, pending building alterations and re-registration to provide for up to eight service users. The home is a large detached Victorian property situated on a main road on the outskirts of Brighton. The home is within easy access to local amenities, and bus routes into Brighton and Hove. The home is presented on four levels, basement, ground, first, second floors. The previous owners used the first and second floors as office accommodation. There is off road parking at the front of the property and a private garden at the rear.287 Dyke RoadPage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The inspection took place during a morning in July 2004 and was facilitated by Ms Floss Croissant, a deputy Regional Operations Manager for the Care Management Group, who has also worked for several years under the previous ownership. The Inspector viewed that factor as having significant relevance to the future continuity of the services to be offered. There have been no changes to the premises since the last inspection. A condition of registration under the new owners is that the building is adapted and the accommodation made suitable for its intended use i.e. for young adult service users, who are both physically and learning disabled. The inspection was necessarily limited to discussion of the intended plans for the home, including a tour of the premises. Choice of Home (Standards 1 ­ 5) 0 of the 0 standards assessed were met. None of these standards were assessed. Individual Needs and Choices (Standards 6 ­ 10) 0 of the 0 standards assessed were met. None of these standards were assessed. Lifestyle (Standards 11 ­ 17) 0 of the 0 standards assessed were met. None of these standards were assessed. Personal and Healthcare Support (Standards 18 ­ 21) 0 of the 0 standards assessed were met. None of these standards were assessed. Concerns, Complaints and Protection (Standards 22 ­ 23) 0 of the 0 standards assessed were met. None of these standards were assessed. Environment (Standards 24 ­ 30) 2 of the 3 standards assessed were met. The home is an old Victorian building with many original features such as large wooden doors, wooden panelling and a large staircase. Much work is needed to the building to make it fit for purpose. The Care Management Group have experience in supporting people with profound needs and understand the limitations that older buildings may present. 287 Dyke Road Page 6 Staffing (Standards 31 ­ 36) 0 of the 0 standards assessed were met. None of these standards were assessed. Conduct and Management of the home (Standards 37 ­ 43) 0 of the 0 standards assessed were met. None of these standards were assessed.287 Dyke RoadPage 7 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report, which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). That any such use of service user accommodation, proposed prior to the up-grading of the premises, is subject to approval by the Commission.MET (YES/NO)YES287 Dyke RoadPage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for actionRECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report 287 Dyke Road Page 9 Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)NA NA NA NA NA NA NA NA NA NA NA NA NA YES NA NA NA YES NA NA X X X YES NA YES YES X X 27/07/04 10.00 1.0The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 287 Dyke Road (Commendable) Page 10 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met(No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.287 Dyke RoadPage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. Range of fees charged From To £ X £ X (per week) NO Any charges for extras If yes, please state what the extras are Key findings/Evidence Standard met? This Standard could not be assessed during the inspection.9Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.287 Dyke RoadPage 12 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.287 Dyke RoadPage 13 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.287 Dyke RoadPage 14 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 9 Key findings/Evidence Standard met? This Standard could not be assessed during the inspection.287 Dyke RoadPage 15 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.287 Dyke RoadPage 16 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.287 Dyke RoadPage 17 Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.287 Dyke RoadPage 18 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to X Accident & Emergency during last 12 months No. of service users with pressure sores at the time of X inspection (from information taken from care notes) Key findings/Evidence Standard met? This Standard could not be assessed during the inspection. 9287 Dyke RoadPage 19 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.287 Dyke RoadPage 20 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the X home during last 12 months No. of these substantiated complaints fully XNo. of these complaints partly X substantiated No. of these substantiated complaints not XNo. of these complaints not yet X resolved No. of complaints sent direct to X CSCI Percentage of complaints X responded to within 28 days 9Key findings/Evidence Standard met? This Standard could not be assessed during the inspection.287 Dyke RoadPage 21 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self-harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) YES which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on X POCA/POVA lists Key findings/Evidence Standard met? This Standard could not be assessed during the inspection. 9287 Dyke RoadPage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. Key findings/Evidence Standard met? 2 The provider and management team are aware of the current limitations of the environmental standards in meeting the needs of the physically disabled. No formal refurbishment plans have yet been submitted to the Commission (CSCI). It has been agreed as a condition of registration (of the new owners, CMG) that no service users may be admitted until the CSCI has inspected the refurbished home.287 Dyke RoadPage 23 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable 1 space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms X below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms X at least 12 sq.m Total no. of wheelchair users accommodated for in rooms X less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite NO NO YES 1 X 1 X 1 X3 Key findings/Evidence Standard met? The home meets the individual space requirements for homes existing prior to transfer of registration to the National Care Standards Commission on the 1st April 2002.287 Dyke RoadPage 24 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence Standard met? This Standard could not be assessed during the inspection. 9Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities, which meet their assessed needs and offer sufficient personal privacy. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. Key findings/Evidence Standard met? 3 Communal space consists of a kitchen dinner and a separate lounge area. The new owners have reported that the plans to increase the registration numbers at the home also incorporate additional communal space.287 Dyke RoadPage 25 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.287 Dyke RoadPage 26 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.287 Dyke RoadPage 27 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High X needs No. service Medium needs users X No. staff allocated No. staff allocated No. staff allocated hours hours hours X X X X Nursing X X XNo. service users Low X needs Total no. needed of hours XTotal Hours ProvidedNo. of staff with NVQ X level 2 or above No. of Trainees registered on Sector X Skills Council training programme No. of full time equivalent Staff with X nursing qualification (where applicable) 9Key findings/Evidence Standard met? This Standard could not be assessed during the inspection.Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.287 Dyke RoadPage 28 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.287 Dyke RoadPage 29 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management NO and care [by 2005]. Key findings/Evidence Standard met? This Standard could not be assessed during the inspection. 9There is currently no manager in place and the organisation plans to recruit to this post once definite plans are in place for the re-development of the home.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.287 Dyke RoadPage 30 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.287 Dyke RoadPage 31 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.Standard 43 (43.1 ­ 43.7) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. Key findings/Evidence Standard met? 9 This Standard could not be assessed during the inspection.287 Dyke RoadPage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceRegulation Inspector Regulation Inspector Regulation Manager DateSignature Signature Signature287 Dyke RoadPage 33 Public reports It should be noted that all CSCI inspection reports are public documents.287 Dyke RoadPage 34 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 27th July 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: 287 Dyke Road Page 35 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNOYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NO287 Dyke RoadPage 36 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.287 Dyke RoadPage 37 - 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. 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