Inspection on 18/10/06 for 29 Shaftsbury Road

This inspection was carried out on 18th October 2006.

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

The inspector found 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

29 Shaftsbury Road 26/04/07

29 Shaftsbury Road 01/11/05

29 Shaftsbury Road 29/06/05

29 Shaftsbury Road 20/12/04

29 Shaftsbury Road 16/06/04

Similar services:

21 High Street

Vale House

Chestnut Walk

The Old Vicarage

Cherwood House Care Centre

Ashley House

Ascot Nursing Home

Fountain View

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

CARE HOME ADULTS 18-65 29 Shaftsbury Road Southsea Portsmouth Hampshire PO5 3JP Lead Inspector Annie Kentfield Unannounced Inspection 18th October 2006 10:00 29 Shaftsbury Road DS0000011831.V310248.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 29 Shaftsbury Road DS0000011831.V310248.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. 29 Shaftsbury Road DS0000011831.V310248.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 29 Shaftsbury Road Address Southsea Portsmouth Hampshire PO5 3JP 02392 754771 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) Southern Focus Trust Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places 29 Shaftsbury Road DS0000011831.V310248.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to be admitted between 18-55 years Date of last inspection 1st November 2005 Brief Description of the Service: 29 Shaftesbury Road provides accommodation for eight service users within the category of mental health. The service is owned by Southern Focus Trust and the manager has recently completed the registration process with the Commission. The home provides accommodation in single bedrooms situated over three floors and the home has two lounges, a kitchen and dining room. To the front of the property are car-parking facilities and to the rear a small courtyard garden that is maintained by the service users. The home is situated close to local facilities in Southsea and is a short journey away from the city of Portsmouth. The current scale of charges is £56.14 per day with no additional charges. Service users who wish to have a TV in their bedroom contribute an additional £5 per year towards the television licence fee. The building is only accessible by steps from the street and stairs internally, there is no lift. 29 Shaftsbury Road DS0000011831.V310248.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In order to provide an overall quality rating for this service information was gathered from a number of sources including an unannounced visit to the home. Comment cards were received from service users and health and social care professionals from the community mental health services. The visit included a tour of the premises, discussion with some service users and staff, and inspection of some of the records. The manager supplied additional information before the unannounced visit in the form of a pre-inspection questionnaire. 29 Shaftesbury Road is jointly managed with 34 – 36 Shaftesbury Road (directly opposite each other in the same road). The manager was not available during the first visit to 29 so some of the records were inspected during an additional visit to the other home when the manager was available to assist with the inspection. The staff on duty at 29 Shaftesbury Road were very helpful and able to provide the inspector with a tour of the building and access to some of the records. Generally, the feedback and comments received from the service users was positive and one person wrote “We don’t want to move”, the only complaint from service users concerned the state of the living room and dining room ceilings, and the poor TV reception. Feedback from health and social care professionals was mixed and comments indicated that the quality of service provided was “inconsistent” and there are concerns about many aspects of the care provided and how well the home works in partnership with the community services. The body of the report will look at these issues in detail. What the service does well: What has improved since the last inspection? 29 Shaftsbury Road DS0000011831.V310248.R01.S.doc Version 5.2 Page 6 The previous inspection in November 2005 made a number of requirements for improvement and these have been mostly met: The home now employs a cleaner for 12 hours per week, however the service was also required to review staffing levels as a whole and this has not been undertaken. A survey of the views of service users, relatives, and visiting professionals has been carried out. The home now has a registered manager. Controls on the water temperature have been fitted. 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. 29 Shaftsbury Road DS0000011831.V310248.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 29 Shaftsbury Road DS0000011831.V310248.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): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have enough information about the home and an assessment of their care needs and choices is in place before they decide to move into the home. EVIDENCE: Service user comment cards said they had enough information about the home before they decided to move in. Some of the service users had lived previously at 34/36 Shaftesbury Road and knew both homes before moving in. The assessment process covers all aspects of health, social and emotional care needs and of the two files looked at – one had been signed by the service user and one hadn’t. There were also copies of letters on file to the service users advising them of the name of their key worker. Other files contained copies of the licence agreement or contract that had been signed by the service users and a copy of the complaints procedure. As good practice, all assessment and care plan information should be signed by the service user and key worker, to demonstrate that service users are actively involved in the assessment and care planning process, (or a reason for it not being signed should be recorded). 29 Shaftsbury Road DS0000011831.V310248.R01.S.doc Version 5.2 Page 9 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): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual care plans show that service users are consulted with about how they make decisions about their lives and participate in life in the home. However, there are inconsistencies about how much detail is recorded about individual goals and aspirations and how these are being met. EVIDENCE: All of the service users were clear in their written comments that they “always” or “usually” make decisions about what they do each day. Care plans should be reviewed each month with the service user and their key worker and updated and records show that this is usually happening. One of the main areas recorded is the cooking assessment to ensure that service users are able to independently purchase, prepare, and cook their own meals. Sometimes this has been identified as an area of difficulty for some service users and more detailed plans of how goals can be achieved should be agreed and recorded in the care plans. In the pre-inspection questionnaire the manager recorded that one service user needed prompting and supervision with meals 29 Shaftsbury Road DS0000011831.V310248.R01.S.doc Version 5.2 Page 10 but it was not clear from the care plan how this support is being provided or monitored. It was evident from discussion with service users and staff that how service users can access social, work and leisure resources is very important and although it is evident that staff are providing support and information this needs to be clearly recorded in the care plans and regularly reviewed to ensure that service users are able to fully benefit from the information and support available. 29 Shaftsbury Road DS0000011831.V310248.R01.S.doc Version 5.2 Page 11 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): 12,13,15,16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are aware of the need to support residents to develop skills, including social, emotional, communication and independent living skills and residents are consulted or listened to regarding the choice of daily activity, but this process could be improved. EVIDENCE: Some of the service users are involved in study or work based activities and staff clearly encourage service users to explore the opportunities available, however, this does not appear to be consistent and there are no systems in place for checking or reviewing practice in this area. Some of the service users were happy to discuss their particular areas of interest in art and photography and examples of their work were on display around the home. The manager has recently been involved in producing a book called ‘Discover to Recover’ a celebration of talent by people who use the 29 Shaftsbury Road DS0000011831.V310248.R01.S.doc Version 5.2 Page 12 mental health services. The book includes some of the work produced by service users at 29 and 34 Shaftesbury Road. There is an area outside of the office that provides a variety of community information for service users but this needs updating and staff need some clear guidance on their responsibilities about how they support service users to access community resources. All of the service users at 29 are expected to prepare their own meals and the Southern Focus Trust makes a weekly allowance of £32.50 to each resident to purchase food. This amounts to between £4 - £5 per day for food and two of the service users commented that this was “not enough”. A kitchen is provided with space for food storage and a fridge/freezer, cooker and other equipment. Staff are around during the day to support residents with cooking and shopping but there are no staff in the home in the evenings when many of the residents will be preparing their main meal of the day, and at weekends there is only one member of staff on duty until 3.30pm. It would appear from discussion with service users that they are satisfied with the staffing arrangements and when asked some said that there have not been any occasions when help from a member of staff was needed in the evening or at night. However, it would be good practice for the staffing arrangements and service user needs to be regularly reviewed and for regular monitoring visits to confirm that service users are happy with this arrangement. Conflicting information was given about how service users get support when staff are not there. Service users said that they would have to ring the member of staff at 34/36 Shaftesbury Road, however, as there is only one member of staff on duty at night over the road, who could not leave the building, the manager said that service users would have to ring the ‘on call’ person who could live some distance away. There needs to be a clear written policy for getting help out of hours, so that service users are clear what to do. If service users wished to ring for help, they would use the payphone in 29 Shaftesbury Road. 29 Shaftsbury Road DS0000011831.V310248.R01.S.doc Version 5.2 Page 13 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): 18,19 and 20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users have access to health care services and this appears to be arranged independently by the service users themselves. The care plans contain general health care information but there are some gaps in the information about how health care needs are met and reviewed. Service users are encouraged to manage their own medicines, however, there are errors in the recording of some medication and staff do not have access to general information about medicines or their effects or side-effects. There is no evidence that staff have been given clear written procedures that describe all of the tasks staff may be expected to undertake when handling medication. EVIDENCE: Comments from service users confirmed that they were happy with the way that staff support them and it evident that staff are very clear about issues of privacy and confidentiality. There were conflicting comments from healthcare professionals and one person commented that they find staff knowledgeable and aware of service users’ needs and another person said that the overall care provided is inconsistent. Records show that there have been regular staff absences that have been covered by agency staff. 29 Shaftsbury Road DS0000011831.V310248.R01.S.doc Version 5.2 Page 14 Staff say that service users are independent in their personal care and can also access their own GP independently. However, although the care plans contained general health care information there was no evidence of a regular review of health care or how health care needs are being met. There was no evidence that staff regularly monitor, as good practice, service users access to dental check ups, eye tests or other health information. Staff were unclear whether any of the service users were registered with the community mental health services on the Care Programme Approach (CPA) or whether any service users were subject to any part of the Mental Health Act. Staff said that where a need has been identified, service users can be referred to community alcohol services, however, there was no record of how this area of care was being monitored or what support was being provided in the interim period between being referred and being assessed. Staff are aware that some service users have previously had problems with alcohol dependence but the policy of the home is that service users may drink in the privacy of their own rooms, but there was no evidence that the use of alcohol is regularly monitored. The home positively encourages service users to manage their own medication where this has been identified in the assessment and there is a system for service users to sign for medication they receive. However, there were errors noted in some of the recording and discrepancies in the dates, also gaps were found in the recording of medication on the medication administration record sheets. There was no information available for staff on what the prescribed medicine was for, what the effects are or what possible side effects there may be and it is recommended that staff have an up to date copy of the BNF (British National Formulary) for medicines or some form of up to date information. Storage of medication was satisfactory and the duty member of staff holds the key to the locked cabinet. However, there are times when medication needs to be dispensed and there are no staff, so service users have to go to 34 Shaftesbury Road to get their medication and some errors were noted in the recording when this happens. There should be a regular review at least 6 monthly with service users who manage their own medication and this was not evident in the files. There was no evidence that medication procedures are regularly reviewed and monitored by the manager or a senior member of staff. There was no evidence that service users’ medication is regularly reviewed with the prescribing person. Staff say that they have received training in the administration and dispensing of medicines and this is arranged with a local pharmacy. The registered manager needs to review the medication training to ensure that staff are fully aware of the home’s policies and procedures for medication and their legal responsibilities to ensure that all medication is correctly recorded and accounted for. 29 Shaftsbury Road DS0000011831.V310248.R01.S.doc Version 5.2 Page 15 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): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users feel their views are listened to and they know who to speak to if they have a complaint. Previous complaints from service users identified at the last inspection have been addressed. Staff are aware of the home’s policy and procedures for the protection of service users from abuse, neglect and self-harm. EVIDENCE: Copies of the home’s complaints procedure were seen in service user files. Service users said in the comment cards that they knew how to complain and would talk to a member of staff if they had any concerns. At the last inspection service users said that the water in the showers, baths and basins was too hot and an immediate requirement was made for this to be assessed. This has been done and running hot water was tested during the inspection and found to be satisfactory. Service users also complained about the difficulties of living in the home because of the behaviour of one of the service users and a requirement that staff review this was made and the situation is now satisfactory. In discussion with one member of staff they confirmed that they were aware of the home’s policy and procedures about protecting service users from abuse or harm. Any concerns would initially be referred to the manager. 29 Shaftsbury Road DS0000011831.V310248.R01.S.doc Version 5.2 Page 16 29 Shaftsbury Road DS0000011831.V310248.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): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home environment provides space suitable for the needs of the service users and is clean and comfortable but is in need of decoration and refurbishment. The home would not be suitable for service users who are not independently mobile. EVIDENCE: Service users said they were happy with the home and liked having their own room that they could personalise in the way they choose. Several service users commented on the poor state of the sitting room and dining room ceilings and also said that television reception was poor. A member of staff explained that there is a problem with TV reception and ways of improving this were being looked at. There is a shared bathroom and toilet on each floor and these were clean but all of the décor is old and tired and some of the flooring in the toilets and bathrooms need replacing where it has become stained and damaged from old water leaks. The previous inspection made an immediate requirement for the 29 Shaftsbury Road DS0000011831.V310248.R01.S.doc Version 5.2 Page 18 hot water system to be assessed for risk of scalding and this has been carried out. Hot water was tested in a number of rooms and was satisfactory. The ground floor sitting room has a stale and musty odour and needs decorating and refurbishment and new carpet. The dining room needs decorating, also most of the stairwell and corridor areas. Staff were not aware of any planned programme of decoration and refurbishment for the home. One service user was in the home and happy for the inspector to view their room. The service user was happy with the room and it contained all the necessary storage and furniture they needed. All bedrooms have a wash-hand basin. The laundry room is in the basement and can be used by service users. There is access to a courtyard garden from the basement and service users have access to this at any time. There is now a part-time cleaner for the home that works 12 hours per week. The cleaner felt that 12 hours was just sufficient to keep the communal areas clean, service users clean bedrooms with assistance and support from care staff. The kitchen was clean and hygienic and there are separate hand washing facilities. 29 Shaftsbury Road DS0000011831.V310248.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): 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are very knowledgeable about the needs of the service users and it is evident that service users feel well supported. There is an ongoing programme of staff training but records need to be kept up to date. A training plan that meets specific service user needs, as well as plans for ensuring that staff meet the National Minimum Standard for NVQ training was not in evidence. Recruitment procedures must be improved to meet regulatory requirements. The last two inspections have made a requirement for staffing levels to be reviewed but there is no evidence that action has been taken on this. EVIDENCE: There are two full-time and one part-time staff who work in the home until 6pm during the week and 3pm at weekends. Recent staff absence has been covered by agency staff from Premier Crew (part of Southern Focus Trust). The last two inspections have said that there is not enough staff on duty to meet the needs of the service users. It is not clear whether the home is not staffed at night because of staff shortages or because the service users have 29 Shaftsbury Road DS0000011831.V310248.R01.S.doc Version 5.2 Page 20 been assessed as not needing support during the evening and night. The manager must provide a clear assessment of the service users’ needs and how these are being met during periods when staff are not in the home. It would appear that staffing has been partly reviewed because there are now additional hours for cleaning provided each week (12 hours). Staff on duty explained that they receive training in all aspects of health and safety and safe working practice and these are regularly updated. One member of staff was in the process of updating training records but these were not complete. One person has recently done some training in mental health awareness and found this very useful. Out of the 3 staff, 1 person has achieved the NVQ level 3 in care. The National Minimum Standard says that at least 50 of care staff should have achieved the minimum qualification in care of NVQ level 2. It would be good practice for there to be a comprehensive training plan in place that includes NVQ training and specific training based on meeting the assessed needs of the service users. Recruitment records were inspected during another visit when the manager was available (and because staff records are kept at 34/36 Shaftesbury Road). The recruitment records did not provide evidence of POVA checks being carried out before staff start working in the home, or give the date when the criminal record check was received, or whether it was satisfactory. A letter was sent to Southern Focus Trust with an immediate requirement about recruitment procedures and the Trust have made a prompt response with their plan of action. 29 Shaftsbury Road DS0000011831.V310248.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): 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is now a registered manager who jointly manages 29 and 34/36 Shaftesbury Road. The manager is committed to providing a safe and homely environment for the service users in both homes. There is an annual quality audit involving service users, relatives and visiting professionals. Health and Safety checks are carried out. The manager must ensure that the home’s policies and procedures include all of those relating to the Mental Health Act 1983, and procedures for staff in the event of an emergency or crisis. EVIDENCE: The previous requirement with regard to the storage and distribution of hot water in the home has been met. The pre-inspection questionnaire completed by the manager confirmed that safety checks are carried out as required by 29 Shaftsbury Road DS0000011831.V310248.R01.S.doc Version 5.2 Page 22 the relevant legislation including tests on the fire alarm and fire safety drill practices. Information was not supplied on when the central heating system was checked or the date of the electrical wiring certificate, however, the manager said that she would locate these and confirm they were in place. The manager has been in post for one year but some of this period was as temporary manager and also managing another service. The manager is now permanently in post and was registered by the Commission in November of this and is keen to ensure that both homes meet all of the National Minimum Standards and Care Homes Regulations. Although improvements are required in the way that the service is run, the manager was open and positive in discussing how these would be met and confirmed that her line manager with Southern Focus Trust supports her. The home does not appear to have policies and procedures for emergency admission under the Mental Health Act 1983, Mental Health Act Code of Practice 1983, physical intervention and restraint, or dealing with emergency and crises. The manager said she was in the process of reviewing policies and procedures and would ensure these are available for staff and service users. A comprehensive quality audit was undertaken in March 2006 and will be carried out annually. The results were made available during the inspection. Service users were all written to individually and offered advocacy support to complete a questionnaire. A number of recommendations were highlighted in the quality audit outcome and further inspections will assess how these have been implemented. 29 Shaftsbury Road DS0000011831.V310248.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 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 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 2 2 X 3 X 3 X X 3 X 29 Shaftsbury Road DS0000011831.V310248.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 12 Requirement Timescale for action 31/12/06 2. YA19 19 Individual care plans must clearly identify, record, and review service users choices, goals and aspirations with regard to all aspects of daily living skills. Individual care plans must 31/12/06 clearly identify, record and review how the health care needs of the service users are being met. The registered manager must ensure that all medication is stored, recorded, dispensed or returned, in accordance with appropriate policies and procedures. The registered provider must provide a plan of decoration and refurbishment that addresses all of the issues highlighted in the report (Environment) The registered manager must provide evidence of POVA checks before staff start working in the home, and evidence of satisfactory criminal record checks. 24/11/06 3. YA20 13(2) 4. YA24 23 31/12/06 5. YA34 19 and Schedule 2 24/11/06 29 Shaftsbury Road DS0000011831.V310248.R01.S.doc Version 5.2 Page 25 6. YA35 18 7. YA33 18 The registered manager must provide evidence of a training plan that meets the needs of service users in the home and identifies when the home will achieve 50 of staff with the minimum qualification in care. The registered manager must review staffing levels and demonstrate there are sufficient numbers of staff available during the evenings, nights and weekends, to meet the needs of the service users. (A review of staffing levels has been required over the last three inspections) 31/01/07 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 29 Shaftsbury Road DS0000011831.V310248.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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 29 Shaftsbury Road DS0000011831.V310248.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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