Inspection on 26/04/07 for 29 Shaftsbury Road

This inspection was carried out on 26th April 2007.

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

The inspector found 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

29 Shaftsbury Road 18/10/06

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 Hampshire PO5 3JP Lead Inspector Mrs Michelle Presdee Unannounced Inspection 26th April 2007 10:00 29 Shaftsbury Road DS0000011831.V332186.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.V332186.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.V332186.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 29 Shaftsbury Road Address Southsea Hampshire PO5 3JP 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) 02392 754771 Southern Focus Trust Silvana David Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places 29 Shaftsbury Road DS0000011831.V332186.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users may be accommodated between 18-55 years of age. Date of last inspection 18.10.06 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 £57.82 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.V332186.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During this unannounced inspection the support worker assisted the inspector. Eight men wee being accommodated, five residents were spoken with and the team leader who was based in the other home was spoken with. The member of night staff who had been on duty at number 34-36 also assisted with the inspection for the first half an hour. No pre- inspection material was received from the manager despite the commission requesting this information. One care manager survey was received, most comments were of a positive nature, but it was stated the use of relief staff unsettled residents. One relative, carers and advocates survey was received. This stated they were unable to visit the home and would welcome more information on their relatives progress. A tour of the home was undertaken and four residents showed the inspector their bedroom. When the inspector arrived at 9:40AM the front door was wide open and one resident was waiting for staff to arrive so he could receive his medication. At ten past ten the inspector went across the road to 34-36, which is a separate service run by the organisation and a staff member came over to number 29. What the service does well: What has improved since the last inspection? One improvement since the last report is the staffing records, which now contain all the necessary checks and information required. 29 Shaftsbury Road DS0000011831.V332186.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. 29 Shaftsbury Road DS0000011831.V332186.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.V332186.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have adequate information before moving into the home to enable them to make an informed choice about the home. Assessments are not kept up to date with the changing needs of residents and do not reflect residents aims. EVIDENCE: The majority of residents in the home have lived there for some considerable time, three living there for over ten years. The latest resident to be admitted, who was not at home on the day of the inspection, moved in a year ago but had been in 34-36 Shaftsbury Road for six years. A statement of purpose was observed on a resident’s notice board. Residents spoken to could not remember if they had adequate information on the home before moving, but all felt they had chosen to come to the home. Assessments seen did not give a full picture of the service user and little information had been recorded from other professionals. Assessments including risk assessments were out of date and did not reflect the current picture for residents. In discussion with a support worker it was clear there had been many changes for both residents, which she was aware of but these were not recorded on an assessment. It was difficult to establish for example how 29 Shaftsbury Road DS0000011831.V332186.R01.S.doc Version 5.2 Page 9 one service user had been assessed as able to part manage their medication but another resident was not able to manage their medication. 29 Shaftsbury Road DS0000011831.V332186.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Individual plans are not kept up to date and reviewed on a regular basis, to ensure they reflect the current situation of each resident. Detailed information on resident’s aims for the future are not present and records do not show how residents are going to be supported and motivated to meet these aims. EVIDENCE: Two care plans were viewed. These gave very little information on how each resident spent their day, what support they needed and what their goals and aspirations were. In discussion with a support worker it was clear there was some knowledge of how residents spent some of their time, but this was not clearly recorded. The member of staff stated it was difficult to motivate residents, which sometimes made it difficult for staff to be motivated. Some new information was recorded with old information making it difficult to establish what the current plan was. For both residents major changes had occurred, which were not recorded on the care plan, no information was available to state how these changes should be planned or the impact they were having on the resident. Information regarding daily living activities was 29 Shaftsbury Road DS0000011831.V332186.R01.S.doc Version 5.2 Page 11 limited, it was not possible to establish was support was needed to maintain personal care, keeping bedrooms and the home clean and tidy, shopping, cooking and leisure activities. Limited information was recorded on leisure activities. One resident was attending an art course three days a week and one resident enjoyed spending time with their family. Apart from this information it was unclear how resident spent their time. Verbally the inspector was informed residents watched television, visited the pub and enjoyed going for a coffee. No information was available on how resident’s nutritional needs were met. Residents are responsible for buying and cooking their own meals from a weekly budget of £32.50. When asked about one resident told the inspector was told he ate cereal with lots of milk. When he was later asked he confirmed this and also stated he regularly went to the chip shop. Care plans were not up to date. They had not been reviewed on a regular basis; the staff member did report, “She had got a little behind”. They did not contain adequate current information. More detail is needed on how future plans are going to be made and how residents are going to be encouraged and motivated to achieve these goals. In one review seen the resident had been involved and in another seen the resident had not been involved. The staff member reported the resident not involved was not interested in reviews, it was agreed this should be recorded on the care plan. Current risk assessments were not available on the care plans viewed. Recent events for both residents indicated risk assessments should have been completed. 29 Shaftsbury Road DS0000011831.V332186.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are not encouraged or supported to take part in a range of activities in the local community. Residents have not developed skills to enable them to independently carry out daily living tasks including shopping, cooking and taking part in community leisure activities. Nutritional assessments are not carried out to ensure residents are receiving a balanced diet. EVIDENCE: From discussions with residents and a member of staff it appeared very little activities were undertaken by residents in the community. One resident attended an art course at University and one resident was involved with local voluntary organisation, which arranged local activities. A member of staff explained it was difficult to motivate residents and stated some enjoyed going to the pub and taking a bus to the local shopping centre. Residents spoken to stated they enjoyed watching television and were enjoying the snooker on the television. Residents had music centres and videos and DVD’s in their rooms, 29 Shaftsbury Road DS0000011831.V332186.R01.S.doc Version 5.2 Page 13 which they stated they enjoyed. Little information was recorded on how residents were encouraged to be part of the community. Residents are welcome to have visitors in the home until 11:00pm at night. A sign welcoming visitors and asks them to sign the visitors book. Two residents have regular visitors and one regularly spends time with family members. Residents are given a weekly allowance of £32.50 per week to buy all their food. It was clear from discussions with residents they did not think this was an adequate amount. It was also clear from discussions with one staff member and residents the meals are not always balanced and not all residents have a healthy diet. Care plans did not detail information on nutrition and state what assistance residents needed to maintain a healthy diet. From discussion with one resident and staff member it would appear he lived off cereals and meals from the chip shop. With the current staffing arrangements no staff are able to support residents in the evenings or after 3:30 on weekends. Residents confirmed they could eat their meals where they chose. Some residents had fridge/freezers and kettles in their rooms. 29 Shaftsbury Road DS0000011831.V332186.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Insufficient detail and the lack of staff does not ensure service users are supported in a manner they prefer and establish that their overall needs are met. Records regarding medication are not clear. It is not clear why one resident can manage some of their medication and another resident cannot. Records do not accurately reflect if medication has been administered or not. EVIDENCE: Residents spoken to on the day stated their privacy was always respected. The one care manager survey received stated privacy and dignity was always respected. Care plans did not detail how personal care was to be provided. When entering one bedroom it was clear the room needed cleaning and in another the bedding was in need of changing. These details were not included on the care plan. In discussion with the staff member it became clear when one service user had been unhappy with a certain situation he had gone to a solicitor for help and had not been able to discuss the situation with the staff of the home. All residents have a key to their own room, which staff would not go into without the permission of the resident. 29 Shaftsbury Road DS0000011831.V332186.R01.S.doc Version 5.2 Page 15 It was difficult to establish if service users health needs were being met. No information was available as to whether residents were registered with the community mental health services on the Care Programme Approach (CPA). Details of those involved with each resident’s health care were limited and it was not possible to establish when they had been reviewed. In two care plans seen it was noted it had been identified both residents needed a dentist however no action or plan had been devised as to how this was going to happen and neither had seen a dentist or had an appointment to see a dentist. The home has a policy and procedures regarding medication. At the current time none of the resident’s totally manages their own medication. Four residents manage their own medication on a weekly basis, which is monitored on a weekly basis by staff members. When looking at care plans and risk assessments it was not possible to establish who had been involved in the decisions to enable a resident to self medicate and who had been involved to state a resident could not self medicate. For one service user the decision to allow him to take his lunchtime medication had changed. This was not recorded in the assessment or the care plan. One resident had just returned home from hospital, the member of staff had to phone the Doctor to see it the night time medication could be given earlier as there was no staff on duty at night. One service user had recently had to go over the road for his evening medication, as no staff are on duty in the evening at this home. When arriving at the home one resident was sat at the front door waiting for his medication. As time went on he became more agitated and stated some mornings he had had to wait until 10.40 before staff had arrived. This is not detailed in the care plan. Medication is checked when it enters the home and is stored in a locked drug cupboard, which only staff on duty have access to. At times of administration residents have to come to the office for their medication, if they do not they are prompted. Each resident signs to state they have taken their medication and the medical administration records (mar) are signed by the staff member. When looking at records an accurate record was maintained, with all refused medication clearly marked. It was noted for one resident a lunchtime medication was enclosed with instructions to take it. However the member of staff reported this had been stopped months ago and sometimes it was added by the pharmacy and sometimes it was not. It was agreed this was very misleading and could easily cause an error, as there was no record on the mar sheets to say this had been stopped. All staff are currently undertaking a 16 week course on medication, which will equip them on the safe handling of medicines. 29 Shaftsbury Road DS0000011831.V332186.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are given information on who to complain to. Staff have a good knowledge on the protection of residents from abuse or self harm. EVIDENCE: The home has received no complaints since the last inspection. The complaints procedure was displayed in the home. All residents are given a copy to keep in their rooms of the leaflet “Your right to Complain”. Residents spoken to on the day stated they would complain to a member of staff; one resident stated he would not complain to the manager, as she was “too bossy”. In discussion with a staff member it was clear they were aware of the home’s policy and procedures relating to the protection of residents from abuse or harm. The staff member stated she had been on a training course, which had covered all types of abuse and the procedures, which should be taken if abuse was suspected in the home. 29 Shaftsbury Road DS0000011831.V332186.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. All areas of the home were not clean and some areas in the home are in need of redecoration and refurbishment for the enjoyment and comfort of residents. EVIDENCE: The inspector was shown around all areas of the home, four residents showed the inspector their bedrooms. Residents stated they were happy with their rooms and had personalised them. It was unclear from discussions with one service user if they were allowed to re-decorate their own room and this room was in need of painting. It was also noted in one bedroom that it was in need of cleaning and in another bedroom there was an unpleasant stale smell and was in need of cleaning and the bed linen changing. In one bedroom the carpet had a few large holes in, which had appeared through age. Another bedroom carpet had cigarette burns in it. Each floor has a shared bathroom and toilet, these were clean but were very basic and it was agreed they had an institutional feel. The décor is old and 29 Shaftsbury Road DS0000011831.V332186.R01.S.doc Version 5.2 Page 18 tired; the flooring in the toilets and bathrooms is stained and damaged from old water leaks. The lounge on the first floor is furnished to a very poor state. The walls need painting after a leak in the roof. The two sofas and one chair are badly stained and showing signs of wear and tear. A cat, which moved into the home seven years ago, takes over one sofa and this sofa was covered in cat hairs. The lounge had a very unpleasant smell. Residents spoken to were concerned about the aerial in the home as they were unable to obtain a good television picture in any area of the home. The inspector was shown in the two communal areas and in some bedrooms. The picture was not clear and had a shadow. The home has a utility area, which has a domestic washing machine and tumble dryer. This leads out onto a courtyard garden, which residents can access at any time. Suitable garden furniture was available, hanging baskets were displayed but currently had no flowers. 29 Shaftsbury Road DS0000011831.V332186.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels do not ensure at all times residents needs are being met. Staffing records contain all necessary checks to ensure the safety of residents. A training plan for each member of staff has not been developed ensuring staff have in-date training in the core areas. EVIDENCE: The duty rota, which covered the week of the day of the inspection, was viewed. This clearly did not reflect the current situation. The home has three care members who cover all duties between 9:30 AM and 6:30pm weekdays and 9:30am 3:30 pm at weekends. The duty rota for the day of the inspection stated three members of staff would be on duty; only one member of staff was on duty for the whole day. The duty rota had four errors on it and clearly did not reflect duty arrangements in the home. The member of staff on duty reported one member of staff had been off long term for an extended holiday and the cleaner was off for two weeks. Some gaps on the rota had been covered by agency staff from Premier Crew (part of Southern Focus trust), but at other times just one member of staff had been on duty. It was clear this had lead to difficulties with keeping the home clean, residents motivated and assessments and care plans up to date. No staff are on duty after 7:00pm at 29 Shaftsbury Road DS0000011831.V332186.R01.S.doc Version 5.2 Page 20 the latest, which causes concern for how residents manage their evening meals and evening medication. For one service user there clearly had been a problem and he had called the emergency services. Another service user spoken to stated he would be happier and feel more secure if there were staff on duty at night. Residents spoken to stated they would go across the road if they were unsure what to do. In discussion with a Team Leader it was felt most attention had been given to 34-36 Shaftesbury Road and number 29 had been “left to get on with it.” Residents and staff confirmed the manager was very rarely present at number 29 and if they wanted to see her they would have to go to number 34-36. The staff records of the three staff members who work in number 29 were viewed. These are kept in number 34-36. It was noted all relevant documentation, checks and references had been obtained. Training records seen in both homes indicated staff do not have in-date training in many areas. The member of staff spoken to was unaware of any organised training programme and stated from time to time she receives emails advising her of courses. For the two full time workers in the home training in fire, food hygiene and moving and handling were out of date. The member of staff on duty had undertaken some training relevant to the residents in the home, which included mental health awareness and care programme approach. Two of the three members of staff working in the home have a National Vocational Qualification Level 2. 29 Shaftsbury Road DS0000011831.V332186.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not have a good system of management and residents and staff are not guided and supported regarding future aims. Health and safety issues do not protect residents. EVIDENCE: The manager has been registered with the commission for seven months and prior to this was working as the temporary manager. Residents in the home were not very positive about the manager and the general feedback was they were pleased she did not spend a lot of time in the home. The member of staff on duty explained the manager did not spend any informal time in the home; the main contact with residents was usually when there was a problem. The team leader spoken to at number 34-36 explained it had been planned she 29 Shaftsbury Road DS0000011831.V332186.R01.S.doc Version 5.2 Page 22 would spend more time in number 29, but so far this had not been possible, due to ‘sorting out’ number 34-36. It was not possible to establish from conversations with residents if they felt their views were taken into account regarding the planning of the home. A full audit was undertaken last March involving all residents and it is planned this will take place again in June. The main two carers, who work in the home, do not have in date training in moving and handling and fire training. From records seen it was clear fire checks in the home are not being carried out in the agreed timescale. Records did demonstrate the fire alarm and fire fighting equipment were being serviced at regular intervals. A fire drill was also needed in the home. No records were available but the inspector was advised the water temperatures in the home had recently been checked and passed. However it was noted the water was too hot in three separate sinks in the home. It was agreed this would be addressed and the company who had completed the water hygiene and temperature checks would be re-called. Coshh (Control of substances harmful to health) assessments could not be found and the staff member was not sure where these were stored. 29 Shaftsbury Road DS0000011831.V332186.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 2 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 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 2 2 LIFESTYLES Standard No Score 11 X 12 1 13 2 14 X 15 3 16 2 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 1 X 2 X X 2 1 29 Shaftsbury Road DS0000011831.V332186.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 (2) (b) (c) Requirement Service users plans must be reviewed and include all details of how support is going to take place and what residents wishes, goals and aspirations are. They must also detail residents nutritional needs and how these will be met. Residents must be included in the plans and reviews. This is a repeated requirement from 18.10.06 Medication records must clearly identify when medication is to be taken. The two carpets identified in the residents’ rooms must be replaced. The lounge needs to be redecorated and re-furbished. This is a repeated requirement from 18.10.06. Staffing levels must ensure residents needs are met at all times. The duty rota must accurately reflect who is on duty at all times. Timescale for action 01/07/07 2 3 4 YA20 YA24 YA24 13 (2) 16 (1) (c) 23 (2) (d) 01/07/07 01/08/07 01/08/07 5 YA32 18 (1) (a) 01/07/07 29 Shaftsbury Road DS0000011831.V332186.R01.S.doc Version 5.2 Page 25 6 YA35 18 (1) (c) 7 YA42 23 (4) 8 YA37 9 A review of staffing levels has been required over the last four inspections. A training programme must be devised ensuring all staff have in-date training in fire, first aid and basic food hygiene. The fire officer must be consulted regarding the frequency of fire drills and servicing fire equipment. The home needs to be competently managed. 01/08/07 01/07/07 01/07/07 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.V332186.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 29 Shaftsbury Road DS0000011831.V332186.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. Re-publishing this information is in breach of the terms of use of that website. 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