Inspection on 27/01/05 for 3 The Droveway

Care Homes For Adults (18 ­ 65)3 The DrovewayHove East Sussex BN3 6LFAnnounced Inspection27th January 2005 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 3 The Droveway Address Hove, East Sussex, BN3 6LF Email address info@cmg-corporate.com Name of registered provider(s)/company (if applicable) Care Management Group Limited Name of registered manager (if applicable) Mr Lee Benson Type of registration Care Home No. of places registered (if applicable) 5 Tel No: 01273 553935 Fax No:Category(ies) of registration, with (number of places) Learning disability (5) Registration number H100000939 Date first registered 31st March 2004 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 7th December 2004 YES NO 20/04/04& 13/05/04 If Yes refer to Part C3 The DrovewayPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 327th January 2005 10:00 am Kevin WhatleyID Code164075Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionLee Benson, registered manager3 The DrovewayPage 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 Agreement3 The DrovewayPage 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 3 The Droveway. 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.3 The DrovewayPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 3 The Droveway was previously part of the Ceres House group of care homes. In June 2004 the group was taken over by the Care Management Group (CMG), who own and operate more than seventy other similar registered care homes, across southern England and Wales. CMG specialise in offering residential care to children, young people and adults who have learning difficulties and complex needs. 3 The Droveway is a converted bungalow and is registered to provide residential and social care for up to five younger adults with learning difficulties; all service users currently accommodated at the home also have complex physical needs and are largely wheel chair dependant. Service users are accommodated in single rooms. Shared facilities include a lounge, dinning room, kitchen and rear garden; though the garden is currently unsuitable for use. The home is located in a quiet residential area on the outskirts of Brighton, close to some local shops and parks. The home has access to transport owned by CMG. Day care provision is provided through the use of the organisations development centre, close by. The homes literature states that some of the homes aims are to provide a caring home like environment, to encourage residents to develop individuality and self-esteem and to ensure that all individual rights to privacy are respected.3 The DrovewayPage 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 unannounced inspection took place during the daytime/evening of a weekday in January. The Inspector found that in general the home was safe, secure, warm and welcoming with an overall feeling that the service being offered appeared to create a relaxed and homely atmosphere to 5 service users. The Inspector found staff to be competent, committed and knowledgeable in relation to their task and witnessed very caring, supportive and creative interactions between service users and their carers. The home clearly has the welfare and wishes of service users at the core of its philosophy and the Inspector was impressed by the amount of service user lead and user friendly interactions that are facilitated within the home. However the Inspector was concerned that the outside/garden area of the home is currently inaccessible to service users, a situation that has remained since the last inspection. The Inspector found that this situation is compromising the general good practice and commitment of the care staff and management team, and indeed is creating a position whereby service users are not having all of their needs met. The Inspector was also concerned about the current meals arrangement and found that care staff and service users alike may have their health and safety, choice and dignity negatively affected should this situation continue. The manager informed the Inspector that he was confident that any requirements or recommendations made as a result of this inspection would be implemented prior to the next inspection, though the Inspector acknowledged that CMG are responsible for implementing a considerable number of these, notably any environmental alterations which are necessary to meet the needs of all service users at the home. The Inspector wishes to note that this report should be read in conjunction with the previous report so the reader can gain the full context of the current situation at the home and the changes implemented since the last report. Choice of Home (Standards 1 ­ 5) 3 of the 5 standards were met, 2 were not met. A satisfactory Statement of Purpose has been produced in a written, pictorial format. The homes aims, objectives and how these are to be achieved are set out in commendable detail. The Service Users Guide has been developed using symbols, photographs and 3 The Droveway Page 6 pictures and is of a high standard. Of concern was the current outdoor facilities of the home which limits service user access and full engagement in their environment. The Inspector was most concerned as this was noted in the previous inspection. The Inspector also noted that service users Terms and Conditions in regard additional costs is still awaiting amendment from the last inspection. Individual Needs and Choices (Standards 6 ­ 10) 4 of the assessed standards were met, 1 was not met. The needs of all service users are well provided for. Daily care planning notes, service users Care plans and risk assessments are well presented and kept up to date. Services are designed to provide appropriate care and support in ways, which maximise independence and choice. The Inspector was concerned that the homes outdoor environment limited the level of choice afforded the service users. Lifestyle (Standards 11 ­ 17) 5 of the standards were met, 2 were not met. Opportunities are provided for service users personal development in keeping with their choices and needs e.g. individual routines and preferences are respected. A wide variety of social and leisure activities are undertaken both in the home and off site. Family links are supported and include regular visits and weekends spent at home. The Inspector commended the positive and pro-active approach taken in this area by the home. The Inspector was concerned that the home does not have a regular/flexible arrangement for the use of the organisations minibus. The Inspector was also concerned that the homes current system for the preparation, transportation and choice of service users meals was reliant on a central process away from the home. The Inspector recommended that service users personal finances be handled within the home and not centrally by CMG. Personal and Healthcare Support (Standards 18 ­ 21) All of the standards were met. Arrangements meeting the health and personal care needs of the service users are satisfactory. The Inspector recommended that a system be developed for the recording of medicines daily administered by day centre staff, and for a record to be kept of medicines taken out on day trip etc. The home has well-established links with a GP surgery that provides for all the; the manager said that specialist support, advice and practice are readily available. Alternative therapies are also accessed for service users e.g. aromatherapy, massage and reflexology. The home has a commendable approach toward Posture Management. The Inspector recommended that staff become familiar with new CMG polices and procedures. Concerns, Complaints and Protection (Standards 22 ­ 23) All of the standards were met. The home has a complaints procedure both for visitors and one for service users that has been produced with the use of symbols for ease of understanding. All staff have received training in the protection of vulnerable adults and understand what constitutes abuse. Environment (Standards 24 ­ 30) 5 of these standards were met, 2 were not met. The home was clean and well maintained to a high standard. Individual bedrooms were decorated and maintained satisfactorily and to the needs and wishes of service users. All necessary laundry equipment was in place and in good working order, as was the relevant fire equipment and the required checks and tests were correct and up to date. Of concern 3 The Droveway Page 7 was the outside/garden area of the home, which needs urgent attention so as to enable service users every opportunity to engage fully in their environment. The Inspector was most concerned as this had been mentioned in the previous inspection. Staffing (Standards 31 ­ 36) 4 of the 4 standards assessed were met. From the duty rota staffing levels in the home appear satisfactory. Each of the staff has relevant previous experience; on-going training is provided, appropriate to the needs of the service users. Staff have a good knowledge of service users needs and were observed to work positively and respectfully with the service users. The Inspector made particular note of the levels of formal supervision and the manager must be commended for implementing such a process. The Inspector made recommendations that staff should gain NVQ 2 qualifications. Conduct and Management of the home (Standards 37 ­ 43) 5 of the 5 standards assessed were met. The manager and staff spoke positively about the change of the homes ownership, now being part of the Care Management Group, and said that they felt well supported under the new management. The new organisation is due to take full financial control of the business in the very near future and therefore staff are due to receive new contracts and terms and conditions of employment. A comprehensive range of policies and procedures have recently been made available from CMG, the Inspector recommended that staff become familiar with them. Records inspected were maintained up to date and accurate. The Inspector was impressed by the general management of the home. The Inspector recommended that the manager continues to study toward completing his NVQ 4 in care management.3 The DrovewayPage 8 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY 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).MET (YES/NO)3 The DrovewayPage 9 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 action The homes statement of purpose and service user guide needs to be altered to make it clear that the garden/outside area of the home is inaccessible to service users at the present time.14(1)(b) 5(1)(c)YA1Immediate25(1)(b)YA5That clear guidelines are included in the Terms and Conditions on any additional charges. (Outstanding from the previous inspection). That the garden/outside area of the home is up dated/altered with a view to it becoming a safe, accessible and stimulating part of the home. That a development plan in relation to this situation be produced with appropriate timescales and a copy sent to CSCI. That the current system for the preparation, transportation and planning of service user meals be assessed in regard health and safety and environmental health regulations. That this current system be assessed in relation to service users, and the home in generals, level of choice and diversity. That the home/CMG address the lack of a regular driver to transport service users in the organisations minibus.1st October 2004 extended to 27th July 2005323(2)(o)YA24 & YA2827th May 2005412(1)(a) 12(3)YA1727th July 2005516(2)(m)YA1327th July 2005 Page 103 The Droveway RECOMMENDATIONS 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 * That the home/CMG develops a more service specific system for dealing with service users personal finances so as to enable more autonomy from the organisation and thus more individual choice to service users. That the home develops a system for the daily recording of medicines administered to service users by day centre staff. That the home records when emergency medicines are taken out of the home on day trips etc, and ensure that they are signed back in if not administered during the day. That staff become familiar with all new CMG policies and procedures and that when completed this is recorded in their individual staff files. That 50 of care staff be qualified to NVQ level 2 in Care. That the manager completes an NVQ level 4 in Care Management. That the home further develops its quality assurance procedures to include a comment card system for visitors to the home.1YA162YA203 4 5 6YA23 YA 40 YA32 YA37 YA39* 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 Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support 3 The Droveway YES YES YES YES YES YES NO NA YES Page 11 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)YES YES YES YES YES NO NO NO YES NO YES 5 0 0 YES YES YES YES 12 X 27/01/05 10:00 6The 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 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (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.3 The DrovewayPage 12 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. 1,742.42 1,742.42 Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 2 Key findings/Evidence Standard met? A Statement of Purpose has been developed which outlines the homes philosophy, aims and objectives, facilities, services provided, and includes a residents charter. The document has been produced in a user friendly manner incorporating the use of symbols and pictures. Similarly a service users guide has been produced which includes all relevant information in relation to the home. The Inspector noted that the statement of purpose does not note the lack of access to the garden/outside areas of the home and made a requirement that work be carried out to address this; in the meantime the statement of purpose should make note of this.3 The DrovewayPage 13 Standard 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. 3 Key findings/Evidence Standard met? The home has a robust system for admitting service users and full assessments are made by the manager who will visit and assess any prospective service user prior to admission, aside from all other accompanying professional referral information. No new service users has been admitted to the home for sometime, many service users arrive at the home having previously been resident in CMG childrens accommodation and therefore consistency is often maintained within the organisation. 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. 3 Key findings/Evidence Standard met? The organisation employs health care professionals, including a physiotherapist, RGN, speech and language therapist, an aroma-therapist and a music therapist. Staff commented that access to such specialised support is readily available and extremely useful to meet the individual needs of service users and the training needs of the care staff team. The involvement of independent advocates at the home is limited, though one service user does have a recently appointed advocate. The manager informed the Inspector that most service users have considerable and regular contact with their families and although advocacy is high on the agenda there are very few options available in the community at present. The core group of staff have worked for the home for many years and have the collective skills and experience to deliver the services. Within the organisation there is a clear commitment to training and development and staff spoken to during the inspection were positive in their attitude toward gaining further skills and qualifications. 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. 3 Key findings/Evidence Standard met? As previously mentioned the specialist nature of the home dictates that any prospective service users would be advised to visit the home along with any placing care manager, family or representative. Additional, trial visits would be arranged, tailored to individual needs e.g. participating in meal times, an overnight or a weekend stay. Permanent residency is subject to a full review of care needs, following a three-month trial period.3 The DrovewayPage 14 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. 2 Key findings/Evidence Standard met? The situation in regard this standard is the same as with the previous report, contracts are made with the funding authority, rather than between the home and the service user; each contract being specific to both agency and service users particular needs. Alongside this formal contract the home has developed a separate statement of terms and conditions of residency, including rights and responsibilities. The previous report made a requirement that this documentation be amended to include clear details of any additional costs of the service, however this has yet to materialise. The manager informed the Inspector that this is expected to be addressed in the very near future when the full take over by CMG is completed this spring.3 The DrovewayPage 15 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. 4 Key findings/Evidence Standard met? The manager and his team have applied considerable effort, ability and thought into establishing a new format for care plans since the last inspection. The newer care plans are legible, relevant and comprehensive. Information is collated about each service user in an all about me folder with help from service users, their representative and others with relevant knowledge, utilising symbolic and pictorial means of communication where necessary. A daily folder contains various daily recording sheets e.g. the physical and medical needs of service users. All care plans were up to date and were commended by the Inspector. Staff informed the Inspector that they found working with the format applicable and easy to understand and maintain. Care plans are reviewed in-house on a three monthly basis, in addition to a yearly review with social service and other external agencies. Good practice was evident in the style of these documents e.g. the language used was non-judgmental and respectful. Acknowledgement was made of the lack of social services attendance and input to a large number of reviews. 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. 0 Key findings/Evidence Standard met? Not assessed on this occasion.3 The DrovewayPage 16 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. 3 Key findings/Evidence Standard met? The nature and complexity of service users needs impacts considerably on their ability to express themselves verbally. The home has developed a pictorial and symbolic format for assisting service users to make contributions toward the day to day running of the home and have utilised the assistance of a speech therapist in gaining greater insight into increasing the level of communication between service users and staff. The Inspector observed good practice in relation to including service users in the homes daily routines and noted that the necessary subtleties of communication and interaction between service users and care staff was of a high standard. 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. 3 Key findings/Evidence Standard met? Care plans viewed during the inspection indicated that all necessary risk assessments had been prepared in a realistic and satisfactory manner without compromising service users choice or opportunity. Risk assessments were clear, legible and applicable and records of reviews, where necessary, were evidenced and dated. 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. 3 Key findings/Evidence Standard met? Service users records are kept in the office of the home and where applicable are secured appropriately. All of the homes written policies and procedures appear to have been prepared with the interests of the service user at their core.3 The DrovewayPage 17 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. 3 Key findings/Evidence Standard met? Service users have access to a number of activity and leisure pursuits. All service users attend a day centre most days of the week, which offers them a full and inclusive programme of activities and learning opportunities. The home also supports service users to maintain friendships that have developed at the day centre and one service user visits a friend nearby in another care home. Communication is consistently addressed and where possible assistance has been provided by a speech therapist whose guidance has given care staff more opportunity to assist service users with their needs. 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. 3 Key findings/Evidence Standard met? The complexity of service users needs indicate that opportunities to maintain employment or attend formal education is limited. However as noted with the previous standard service users attend a day centre in close proximity to the home five days a week and engage in number of activities suited to their needs and abilities. Staff accompany service users to and from the centre and support them whilst they are there. Staff also accompany and support service users to go on shopping trips, the theatre and the cinema, allowing for individual choice wherever possible. Service users likes and dislikes in relation to activities and interests are recorded in their care plans.3 The DrovewayPage 18 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. 2 Key findings/Evidence Standard met? Wherever possible service users are empowered to engage in their local community such as regularly visiting the local shops and facilities and travelling on public transport etc. The Inspector noted that the lack of a regular driver for a minibus, that is shared amongst other local CMG homes, may reduce the opportunity for service users to participate in local activities or events, notably if these events are not served by a suitable bus service. The Inspector made a requirement that suitable arrangements be put in place to ensure the minibus is more accessible as and when it is needed. Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? Service users have good access to activities and leisure pursuits and participate on a regular basis in swimming, walking, dancing, cinema trips and pub visits. Such activities are recorded in care plans and reviewed to meet the individual wishes of service users. The manager has a budget, which is designated for use on activities and leisure; service users pay only for any personal expenditure. The organisation has its own mini buses. The staffing structure enables service users to be escorted out on a regular basis. The home is planning to take service users on an annual holiday later this year. 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). 4 Key findings/Evidence Standard met? Service users are actively encouraged to maintain links with their family, carers and friends. The home operates an open door policy in regard to reasonable visiting times and service users appear to have a high level of contact with their families during the week. The Inspector was impressed by the support given to service users by care staff to facilitate such contact, with the use of mobile phones and `texting utilised to maintain contact on a regular basis. The Inspector observed commendable support in relation to one service user whose mother was currently hospitalised, the encouragement and pro-active approach by staff enabled and empowered this service user to maintain links at a difficult period both for himself and his mother. Service users are also assisted by care staff to establish and maintain friendships outside of the home, for instance facilitating visits with service users friends they had made during their day centre contacts.3 The DrovewayPage 19 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). 3 Key findings/Evidence Standard met? The Inspector noted that service users personal finances are dealt with centrally by CMG and that access to personal funds may be delayed as a result. The Inspector recommended that the manager should be allowed more autonomy in relation to service users personal finances and allowances, therefore service users personal choice of what to purchase and when will not be compromised by procedure. The manager informed the Inspector that he was aware that the home would soon be given more responsibility to manage service user finances. 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. 2 Key findings/Evidence Standard met? The home currently has a majority of its meals prepared at another CMG home located nearby and care staff are responsible for collecting the food, bringing it back to the home where it will often be re-heated prior to service users consuming it. There are guidelines regarding re heating and food preparation in the kitchen area of the home. Meals are taken together in a suitable and relaxed dining room area of the home and the menu viewed indicated that service users receive a varied and nutritious diet. On the day of the Inspection the service users and staff had decided to order in a `take away meal, something that occurs should service users wish it. The manager informed the Inspector that if the home wishes to cook for themselves, or order in food, they have to give considerable notice to the CMG cook to cancel their meals. The Inspector was concerned that the transportation of food posed both health and safety and environmental health issues for care staff and subsequently service users at the home. Such a system may also compromise service user and the homes choice in relation to providing for individual wishes and tastes as and when service users request them. The Inspector therefore made a requirement that this standard must be addressed. The home should request an assessment/review of their procedures from their local Environmental Health Department to ascertain whether a more suitable `in-house arrangement can be developed.3 The DrovewayPage 20 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. 3 Key findings/Evidence Standard met? The home does not provide nursing care, however the service users have complex health care needs and require care staff to have a clear and knowledgeable understanding of all the service users needs both day and night. Service users require assistance with many of their personal care needs and the Inspector noted that care staff were considerate, supportive and competent in respecting both the individual needs of service users and the collective needs of the home in a calm and caring manner.3 The DrovewayPage 21 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 Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) X03 Key findings/Evidence Standard met? The home does not provide nursing care. However, all service users have complex needs including specific health requirements. One GP is used across the organisation due to their specific skills and knowledge of complex physical needs. An alternative GP would be provided, should this be requested. Service users health care information is held within the home, the manager is responsible for liaising with health care professionals with support from the Therapy team (Speech and Language and Physiotherapist). Staff are instructed to contact the on-call person if medical intervention is needed, who would then make the decision to seek medical assistance; in the event of an emergency an ambulance would be called. The Inspector noted that members of staff are not allowed to administer medicines or liquid feeds without having first undertaken the necessary training. Staff observed and spoken to during the inspection appeared to have a satisfactory understanding of each service users medical needs and were competent in the procedures they carried out. The home has a strong emphasis towards postural management and clear guidance is provided to staff on how to use the necessary equipment, and the reasons and risks behind such and approach, including the measures to prevent tissue breakdown. The Inspector was impressed by the level of staff competency and knowledge in this area.3 The DrovewayPage 22 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. 3 Key findings/Evidence Standard met? Given the severity of the service users learning difficulties no service user is able to self medicate. Medical records viewed during the inspection were all up to date and correct with a clear administration procedure in place. Only staff who have had the necessary training are required to administer medicines. Service users who require medicines during the day when they are at the day centre have their medicines signed out form the home and transported by staff to the day centre who subsequently take responsibility for storage and administration. The Inspector recommends that the home develops a system for recording that service users have taken their medicine at the day centre on a daily basis rather than receiving a copy of the day centres administration records at the end of the week. The Inspector also recommended that the home develops a recording system of when emergency medicines, such as Diazepam etc, are taken out by staff when service users are going out on activities. The homes manager had compiled a satisfactory system prior to the end of 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. 3 Key findings/Evidence Standard met? Due to the relatively young age of service users, deaths within the home are rare. The homes philosophy of care is for service users to remain in the home for as long as possible with the support from health care professionals. Written guidance is available for staff, which details the actions to follow in the event of a service users death. Staff have experience of supporting service users, who are terminally ill, and have done so with care and sensitivity, taking into account the needs and preferences of service users and their representatives. The manager is also sensitive towards the after care needs of service users and staff.3 The DrovewayPage 23 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 home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 X X X X 0 X 3 Key findings/Evidence Standard met? The home have robust and comprehensive complaints procedures in place and have included how to make a complaint in both pictorial and written format within service user guides. The home also clearly displays its procedures in the home with information for relatives/carers and professionals.3 The DrovewayPage 24 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) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES03 Key findings/Evidence Standard met? The home has recently received new comprehensive policies for the protection of vulnerable adults from CMG. Staff spoken to during the inspection appeared to have a clear understanding of how such polices should work in practice and why. The Inspector recommends that all staff should familiarise themselves with CMG policies and procedures and when completed that this be recorded in staff/training files. All staff files viewed during the inspection contained clarification form CMG human resources that the necessary Criminal Records Bureau (CRB) checks had been carried out.3 The DrovewayPage 25 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. 1 Key findings/Evidence Standard met? The home appeared clean, tidy, warm and homely, in a good standard of decorative order that had been thoughtfully created. The home has level access indoors and all doors had been fitted with the necessary magnetic fire release equipment. All fire and health and safety regulations had been adhered to and records relating to these were up to and complete. However the garden area of the home is in urgent need of attention as it is currently not accessible to service users and appears both unsightly and unsafe. The Inspector was concerned that this requirement was made following the last inspection and no efforts appear to have been made since to address this standard. The Inspector therefore made a requirement that these issues be addressed as soon as possible and that CSCI be given a plan of action to determine how and when the work will be completed.3 The DrovewayPage 26 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 space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms 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 Key findings/Evidence The home meets this standard. YES NO NO 5 0 0 0 Standard met? 3 5 05 0 0 03 The DrovewayPage 27 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. 3 Key findings/Evidence Standard met? All service users have bedrooms that contain sufficient space and privacy, which have been decorated to a high standard. All bedrooms have been prepared and maintained with each service users individual tastes and wishes taken into account. All bedrooms have the necessary equipment fitted and all appeared in good working order.Standard 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. 3 Key findings/Evidence Standard met? There is one assisted bath and toilet and service users are assured personal privacy. These areas were clean, hygienic and decorated to a high standard.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. 2 Key findings/Evidence Standard met? The interior of the home comprises of two main communal areas, which offer service users adequate space and comfort. The interior is decorated appropriately and to a high standard, the Inspector was most impressed by the interactive work that has taking place within the home notably the communal display area. Themes are addressed regularly, such as cultural events, times of the year, and staff and service users produce art work, decorations etc to denote the current theme; the theme at the time of the inspection was Chinese New year. The homes kitchen is also wheelchair accessible. The Inspector was most concerned that due to the garden area being inaccessible that service users were not gaining the most from an environment that could be utilised for their relaxation, leisure and sensory needs (see also 24).3 The DrovewayPage 28 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. 3 Key findings/Evidence Standard met? The organisation employs a Physiotherapist, who has been involved in providing advice about necessary adaptations, aids and equipment, also in providing staff training and advice on their use. The home has much equipment in evidence to support service users needs. There is a strong emphasis towards training on postural management and the use of specialist equipment across the organisation. Fixed and portable listening monitors are used during the night, it was reported that this was to support service users medical needs. Protocols have been developed on their use to prevent any potential infringement on human rights.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. 3 Key findings/Evidence Standard met? The home was very clean with no obvious signs of insufficient hygiene care. There were no offensive odours and all bedrooms and communal areas appeared maintained to a high standard. The home has a suitable laundry facility and procedures for the prevention of the spread of infections are clearly displayed in relevant areas.3 The DrovewayPage 29 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. 3 Key findings/Evidence Standard met? As the home has recently been taken over by CMG from the previous Ceres group care staff are due to receive new job descriptions and contracts in April this year when the full takeover process is completed. Staff files viewed during the inspection do have job descriptions though it is envisaged that the new contracts will contain more concise and descriptive staff roles. Staff spoken to during the inspection appeared to have clear understanding of their role and tasks and that of colleagues. 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. 2 Key findings/Evidence Standard met? All staff spoken with and observed during the inspection appeared competent, committed, caring and respectful toward all the service users. Staff had a clear understanding of service users needs and carried out their tasks with sensitivity and thought. Two members of staff currently hold an NVQ level 2 in care whilst a further two are currently undertaking the qualification. All staff are required to participate in a full induction programme and are expected to study toward NVQ level qualifications. The manager informed the Inspector that it is envisaged that the home will continue to progress toward having the required number of NVQ level qualified staff, though there are some difficulties with having short term and night staff in post who are unlikely to have the necessary time to complete such training. The Inspector recommended that 50 of care staff be qualified to NVQ level 2 in care.3 The DrovewayPage 30 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 needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 5 X X X 2 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXX3 Key findings/Evidence Standard met? Staff currently employed bring a range of qualifications and experience to the home, together with the personal qualities and values needed to work positively and respectfully with service users. Given the complexities and levels of care that service users require it appears that the manager has worked hard to establish a stable, suitable and competent care staff team. 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. 3 Key findings/Evidence Standard met? The home operates under CMG polices in relation to recruitment. Such polices are comprehensive and in line with necessary legislation and guidance. Potential care staff apply to CMGs central human resources department in the first instance from which an initial suitability assessment is made prior to being passed to the home. The homes manager then gains responsibility for continuing the application and proceeds to carry out the interview process. The manager said his wishes in regard suitability of potential employees is respected by CMG and felt confident that such decisions are made in the best interest of the service users and the home in general.3 The DrovewayPage 31 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. 3 Key findings/Evidence Standard met? Staff are expected to engage in a full induction programme linked to the Learning Difficulties Awards Framework (LDAF) and on-going/refresher training is a key part of CMGs philosophy. Staff files viewed during the inspection indicated that a considerable number of staff have undertaken training in respect of Health and Safety, Manual Lifting, Administration of Medicines, First Aid and Infection Control. Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 4 Key findings/Evidence Standard met? Records viewed during the inspection indicated that formal supervision is currently taking place on a monthly basis, this exceeds this standard. The manager was able to inform the Inspector as to the format of such supervision and the Inspector was impressed by the ongoing supervision agenda that each member of care staff has and the positive steps being taken to link supervision to staff development and training. Staff spoken to expressed their support of the current system of supervision and informed the Inspector that they found such sessions supportive, positive and relevant for the nature of their tasks. The home also has monthly group staff meetings where relevant issues, concerns and thoughts are shared and recorded. These monthly meetings are also used to invite care professionals to address care need issues within the home such as Speech Therapy and Posture Management.3 The DrovewayPage 32 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 and care [by 2005]. NO2 Key findings/Evidence Standard met? The manager is competent, experienced and committed to the needs of all service users and staff within the home, approaching such work with a realistic and enthusiastic attitude. The Inspector was impressed by the relaxed and supportive manner in which he conducted himself with staff and service users alike, and wishes to make note of the considerable amount of positive changes that have been implemented at the home since the last inspection. The manager is currently undertaking the Registered Mangers Award (RMA) which is due to be completed this summer. The manager informed the Inspector that when this is completed he will continue to study toward obtaining an NVQ 4 in Care Management.3 The DrovewayPage 33 Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 4 Key findings/Evidence Standard met? The Inspector found the management approach of the home had created an atmosphere that was open and inclusive for both staff and service users alike. Staff spoken to during the inspection appeared motivated toward their tasks and commented that they felt supported and valued by the manager and senior staff. The Inspector noted that the overall milieu of the home was homely, caring, positive and encouraging.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. 3 Key findings/Evidence Standard met? CMG as an organisation send out questionnaires to the families and carers of service users on an annual basis, the feedback received is subsequently recorded. The home are in close contact with service users families, carers and social care professionals and informal feedback is gained regularly as a result. The Inspector recommends that the home develops further a system of recording informal feedback, such as using comment cards for visitors to the home to complete should they wish. 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). 3 Key findings/Evidence Standard met? The home have recently received new policies and procedures from CMG. All documentation appears to conform to all the necessary standards and legislative requirements. The Inspector recommends that staff become familiar with all new CMG policies and procedures and when completed that this be recorded in their staff files (see also standard 23).3 The DrovewayPage 34 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. 3 Key findings/Evidence Standard met ? All records viewed during the inspection were clear, legible and up to date with those protected under the Data Protection Act being securely stored appropriately. Service users have open access to their daily care plans that are completed and updated with them by a member of staff every day. All service user contracts and terms and conditions have either been signed by them or by a family member/carer.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. 3 Key findings/Evidence Standard met? There is a comprehensive range of policies and procedures relating to health and safety matters. Records relating to fire safety were in order and a fire risk assessment has been undertaken. Regular fire drills are carried out and the record showed the names of those attending each drill. An electrical fixed wiring installation check has recently been undertaken and a regular health and safety/ environmental check is carried out and recorded. Staff have received training appropriate to health and safety issues within the home. 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. 3 Key findings/Evidence Standard met ? Monthly monitoring visits by the registered provider are completed in detail and recorded with a copy forwarded to the Commission. The home has a certificate of public liability insurance. The manager has taken fuller responsibilities for the provisions and social expenses budgets, and informed the Inspector that sufficient funds are available to run the home adequately. The new owners produced a business and financial plan at the point of their Registration.3 The DrovewayPage 35 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorKev WhatleySignature Signature SignatureRegulation Manager Mr Chris Stanley Date3 The DrovewayPage 36 Public reports It should be noted that all CSCI inspection reports are public documents.3 The DrovewayPage 37 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 January 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: 3 The Droveway Page 38 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 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 NO3 The DrovewayPage 39 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.3 The DrovewayPage 40 3 The Droveway / 27th January 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000060763.V199032.R01© This report may only be used in its entirety. 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