Inspection on 16/10/06 for 30 Church Road

This inspection was carried out on 16th October 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

CARE HOME ADULTS 18-65 30 Church Road 30 Church Road Locksheath Hampshire SO31 6LU Lead Inspector Mrs Pat Hibberd Unannounced Inspection 16th October 2006 09:00 30 Church Road DS0000067289.V311862.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 30 Church Road DS0000067289.V311862.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. 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 30 Church Road Address 30 Church Road Locksheath Hampshire SO31 6LU 02380874300 01489 570084 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) www.hantspt.nhs.uk Hampshire Partnership NHS Trust To Be Confirmed Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: 30 Church Rd is one of a number of Home’s managed by Hampshire Partnership Trust and owned by Downlands Housing Association. The Home is currently managed by a temporary manager with the support of a team of support workers. Church Rd is situated in the village of Locks Heath a short journey from the town of Fareham that has a range of shops and leisure facilities. The Home is a detached property, domestic in style and has been adapted on the ground floor for disabled access. There are four bedrooms, communal areas and a large garden. The service is registered to provide accommodation and support for up to 4 service users with a learning disability although one individual has an additional physical disability. The current fees are paid through a block contract with Adult Services. 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Since the last inspection 30 Church Rd has had a change of Provider with Hampshire Partnership Trust now responsible for service provision. The visit to the Home was unannounced and all key standards were inspected on this occasion. The fieldwork took place over 4 1/2 hours and the inspector was able to tour the home, garden, view all of the bedrooms and communal area. Discussions were held with the Home’s temporary manager, the area manager and four staff members. The inspector spoke with two service users and spent time observing staff interaction and support with service users as detailed in their care plan. Additional information was supplied within a pre-inspection questionnaire completed by the Home’s manager. Prior to the inspection two relative comment cards were received by the commission of which views expressed as to the service provided by the Home are included within this report. Comment cards were also received from service users indicating that they were happy with the care and support they received from staff. From observations of service users during the inspection it was evident that they were comfortable and happy living in the home. Documentation demonstrated that they are involved in decisions reached about their home and, that they consider the staff treat them well. Two service users’ files and one staff file were viewed which further contributed to the findings of the inspection. What the service does well: What was evident during this inspection was the commitment by the staff team and manager to ensure the service offers a person centred approach to all care provided to service users accommodated and, within a risk management framework of care. From discussions held with staff and the home’s temporary manager it was evident that much work has been undertaken to ensure each individual service user has detailed care plans that are put into practice. This was further supported from observations of care practice and information displayed on the communication board in the dining room. A great deal of work has been undertaken by the staff team to ensure service users are individuals with individual communication/care needs. 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 30 Church Road DS0000067289.V311862.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 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a comprehensive assessment process ensuring service users’ needs are identified by the home prior to admission although information held in the Statement of Purpose and Service User Guides must be up to date. EVIDENCE: The temporary manager advised that there have been no changes to the service user group in the Home for many years. However, 30 Church Rd have an extremely comprehensive process of assessment that would be undertaken by the Home’s manager prior to a placement being offered to a prospective service user. The process would include a prospective service user visiting the Home prior to a placement being offered during which time interaction between service users currently accommodated would take place and staff views gained. A number of visits would take place before a firm offer of a placement is made including an overnight stay. The manager advised that the process would take as long as the prospective service user needed and would involve care managers and all relevant personnel involved in the individuals life. The Home does not admit service users on an emergency basis. 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 9 Although Standard 1 is not a key standard a discussion was held with the manager regarding The Statement of Purpose (SOP) and Service User Guide both of which have not been updated to reflect the increase in mileage costs charged to service users when using the Home’s vehicle. The previous manager was also named in the SOP and is required to be amended to reflect the current management arrangements. The temporary manager agreed to amend the documentation immediately and send a copy of the SOP to the commission. 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are care planning and risk assessments in place which provide staff with the information required to meet the needs of service users and enable service users to make decisions about their lives. EVIDENCE: Two service users’ care plans were viewed during this visit. It was evident that a great deal of work has been undertaken to ensure staff have the information they need to appropriately support service user’s accommodated. It was further evident that the plans and guidelines are referred to on a daily basis alongside good systems of communication that have been developed to continually inform the reviewing process which include shift “handovers”, completion of daily records, informal discussions and staff meetings. Staff spoken to had a good understanding of individuals’ needs, and were seen to interact appropriately. Choices and decisions made by service users were seen to be well supported by staff, and in accordance with current risk assessments held in files. Examples of choice included service users being given the option on the day of 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 11 the inspection of going out for a meal, activities they wished to pursue and evidence throughout documentation read that the service user had been fully involved in all decision making. Due to some communication difficulties staff support was provided to two service users to enable the inspector to confirm from discussions and records seen that both were happy living in the home and were able to exercise choice with day to day matters. An area of good practice included the use of pictures to enable service users to determine what they having for each meal and, the planning of their daily routine. The notice board in the dining area displayed photographs of staff on duty throughout the day with one service user indicating that they were aware of the board and who was on duty that afternoon. Care plans had clear measurable objectives based on multidisciplinary assessments of need and risk for all service users accommodated and included a detailed personal centred planning approach to the care planning process which more accurately reflects the views, aspirations and choices of individuals. Apart from day to day issues, all plans highlight areas of special needs and any additional help required including how best to communicate with individual service users. Although service users may have difficulty in totally understanding the concept of risk and consequently are unable to fully exercise unrestricted choice and make valid safe decisions staff indicated that they had a right to take risks. Two files viewed held detailed risk assessments including action to be taken by staff to minimize risks and hazards without limiting the individuals preferred activity or choice. 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities, family contacts and meals are well managed providing service users with choice, independence and opportunities for personal development both in the home and community. EVIDENCE: From discussions held with staff and care plans viewed service users have individual programmes of activities with opportunities arranged to enable them to have a varied and interesting lifestyle. Activities include day services, additional one to one personal community support and various activities provided in the home. One service user goes to football and all have the opportunity to go for walks, shopping and have a holiday if they so wish. 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 13 The temporary manager indicated that the Home also endeavour to ensure service users are a part of, enjoy and regularly access community based facilities such as swimming pools, shops, cafes and libraries etc. The Home has its own transport that is available and used by all service users when going out to local events shopping and leisure facilities. The vehicle has been adapted to accommodate a wheelchair. Service users have contact with family and external friends who are encouraged to participate in the service users review if agreed by the service user. No service user has an advocate although the temporary manager indicated that a service in Fareham would be approached if one was required. A written format of the Home’s menu was seen on the fridge door in the kitchen although the Home is currently compiling a pictorial format to support all service users in the Home to be aware of the days’ meals. The menus appeared to be balanced and nutritional. Staff explained that service users’ choices and personal preferences are discussed with the individual and incorporated within the menu planning process. Details of the specific support required for one service user when eating was detailed in their care plan with staff indicating that they were fully aware of the individuals needs. In discussion with one staff member they explained that service users are encouraged and supported to plan the shopping list, purchase the food and prepare the meals. The kitchen has recently been renewed and includes an area of worktop that has been specifically built to a height suitable for the service user who uses a wheelchair. Staff explained that he could now be supported to make a drink and prepare a snack in the kitchen enabling him to have a degree of independence as detailed in his risk assessment. 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health needs of service users are met with evidence of good multidisciplinary working taking place on a regular basis with personal support provided in a way that promotes and protects their privacy and dignity. The Home’s medication policy and procedure is being adhered to and protects service users. EVIDENCE: Documentation viewed indicated that service users’ health care needs are met, with appropriate support from staff to attend various appointments where necessary. There are clear guidelines for staff within care plans on how to support personal care, based on the individuals’ preference. Health needs are closely monitored, with the support of the Community Learning Disability Health Care team and referral to appropriate specialists as seen within files. Two files viewed confirmed that the service user has access to a local GP, dietician, speech therapist, community dental and chiropody services, and optician. Service users retain their own daily medication that is held in a blister pack in a locked drawer in their bedroom with the key held in a separate drawer also in their bedroom. However, the temporary manager explained that service 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 15 users do not self-administer, as they would not have a concept of when or how to take their medication independently. Support is therefore provided by staff as detailed in risk assessments that are regularly reviewed. The temporary manager explained that this routine has been in place in for a number of years with no issues having arisen to place any of the service users at risk. He further explained that this routine enables service users to have some degree of independence and ownership of their medication. The inspector was unable to clarify with service users their understanding of the process in place. There is also a locked medication cupboard in the staff sleep- in room that holds some prescribed medication and PRN (as required) medication. Staff spoken to were able to explain how the guidelines of administering PRN are put into practice and the importance of ensuring they were aware of how to support an individual and “triggers” that may cause a service user to become upset and agitated. PRN medication is only administered as a last resort and after consultation with a senior member of management. Staff have received training in administering medication as well as a refresher course. The inspector looked at the medication cupboard and one service users medication drawer in their bedroom and found that the supply matched the records. There are currently no controlled drugs administered. 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A complaints policy and procedure and alternative systems are in place to ensure that service users concerns are addressed. Staff have a good understanding of adult protection issues, which protects service users from abuse. EVIDENCE: The Home has a complaints procedure that is produced in a pictorial format of which service users are provided with a copy in their service user guides. The inspector was unable to determine with individuals as to their understanding of the procedure although the manager confirmed that relatives and representatives are provided with a copy. From care plans viewed and discussions with staff it was further evident that they had a good knowledge of the indicators service users would display if they were unhappy with any aspect of their care. For example one service user was eager to go out and indicated through facial expressions and gestures that they were getting impatient and did not want to talk to the inspector any longer!! Staff indicated to the inspector and demonstrated a thorough understanding of how the individual was communicating with them. No complaints have been made to the Home since the last inspection. A complaints book was in place. The Home has all relevant documentation relating to adult protection including a whistle blowing procedure, the adult protection policy and the “No Secrets” guidance. Staff had received training in abuse with one staff member discussing a scenario and how they would respond to a disclosure. 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 17 There have been no Adult protection investigations in the last twelve months in the Home. 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comfortable, clean, hygienic and safe environment is provided for service users, which meets their needs. EVIDENCE: All areas of the Home including the garden were viewed. The Home was well furnished, fully decorated, clean, free from adverse odours and homely. It was evident from discussions with staff and observations of service users that the environment meets the current needs of service users accommodated. All service users have their own bedroom that were seen to be personalised and reflective of the individual as detailed in there care plans. The Home has a lounge/diner that provides a comfortable and homely environment for service users. Service users were observed as being relaxed and comfortable watching television whilst waiting to go out for lunch. There is a good size kitchen that has recently been renewed and was clean, bright and airy. 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 19 COSHH (control of substances harmless to health) sheets are available for staff. There is a separate laundry with a washing machine fitted with a high temperature programme and sluicing mode. Staff have received training in food hygiene and infection control. The Home has polices and procedures in relation to infection control although these were not inspected on this occasion. There is one service user accommodated who requires a wheelchair to access all areas of the Home and garden. The front door is accessed by a ramp and there is a walkway to the back garden to ensure the service user can make use of the area if he so wishes. The individual has his own on-suite that has overhead tracking and an adapted bath. However, the bath is not currently in full working order as the mechanism allowing the bath to rise and fall has broken. The temporary manager explained that he is aware of this and is endeavouring to address the problem. The service user is still able to use the bath and staff explained how they have been instructed by an appropriate professional as to an alternative and safe moving and handling procedure. A discussion was held with the temporary manager and Team leader as to requirements made by the statutory Fire officer in 2005. A visual check was then made of the Home and all requirements identified were confirmed as being met. The Home has a planned maintenance and renewal programme. 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are sufficient staff that are well trained to support service users. Documentation in place in the Home does not demonstrate that the relevant recruitment practices in place ensure service users are protected. EVIDENCE: There are currently four fulltime and one part time staff member employed in the Home supporting service user’s accommodated. Rotas viewed indicated that there are sufficient staff on duty to meet the needs of service users with a total of 337.30 hours worked flexibly over seven days to meet the needs of individuals. However, there is a high use of agency staff in the Home with 117 shifts having been covered in the last eight weeks. The temporary manager explained that there have been difficulties recruiting permanent staff although the use of agency staff should decrease with two permanent staff recently appointed awaiting a satisfactory Criminal Record Bureau check. One permanent staff member told the inspector that the agency staff are generally known to the staff team and service users and that there have been few issues or difficulties experienced. 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 21 All agency staff are required to have mandatory training including abuse awareness prior to commencing work in the Home. The temporary manager further explained that agency staff would work alongside permanent and experienced members of staff and that an induction pack has been developed to ensure agency staff have the information they need to support service users accommodated .The temporary manager further explained that he is commencing monthly supervision with agency staff. All staff spoken to including an agency staff member demonstrated an excellent understanding of service users’ needs and were observed as being approachable, good listeners and communicators and supportive of service users’ requests throughout the inspection. Staff indicated that a range of training is provided relevant to the needs of service user’s accommodated. This includes a thorough induction week when staff receive training in health and safety, abuse, infection control, moving and handling, fire, medication, basic first aid and basic food hygiene. Of the 5 staff members of the team 1 has achieved National Vocational Qualifications (NVQ) in care Level 2 and two are on the waiting list to commence the qualification. One staff member spoken to demonstrated an awareness of equality and diversity issues and application to their daily practice describing how they support individuals to be a part of the community and pursue their interests with appropriate support and informed choices. There is an equality and diversity policy and procedure in place in the Home with the temporary manager explaining that relevant issues are discussed with staff during staff meetings and supervision with a view to sharing ideas and understanding as to the implications of the policy on service delivery. One staff member spoken to say that they have training needs analysis and opportunities to develop their practice with the support of the manager. Updates of core training such as fire safety, food hygiene, first aid moving and handling are mandatory for all staff. All training needs are reviewed on a regular basis through supervision. Hampshire Partnership Trust have a comprehensive training calendar of which all staff can access and apply for courses as needs arise. Additional courses undertaken by staff include social induction, basic life support, bowel care and Strategies for crisis intervention and prevention (SCIP). Staff records viewed did not hold all information as required in the Care Home Regulations. The inspector was unable therefore to confirm that all staff are employed in accordance with the corporate recruitment and selection procedure.However, the temporary manager and Team leader explained the process which involves all staff completing an application form, signing a rehabilitation of offenders declaration, undertaking an interview, satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) and reference checks followed by the satisfactory completion of an initial probationary period of employment. The temporary manager and Team leader explained that the previous Health Trust held all personnel files centrally in their Human Resources Department 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 22 and, that, at previous announced inspections the documentation was always obtained prior to the inspection and therefore available in the Home. However, it was acknowledged that the majority of visits to the Home by the commission are now unannounced and therefore plans were agreed to be put in place for this information to be readily available for inspection in the future. Supervision is provided monthly or sooner if identified with one staff member on duty confirming that they received regular supervision and support from the temporary manager. 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The temporary manager ensures that outcomes for service users are positive and that staff and service users are involved in the running of the service. The health and safety practices in the home promote the welfare of service users. EVIDENCE: As detailed throughout this report there is currently a temporary manager in post. The Team Leader explained that interviews for the vacancy had taken place in September but an appointment was not made. Further interviews are to take place shortly. The temporary manager is an experienced Home manager who is currently seconded from a supported living Home on a four day week basis to oversee the management of 30 Church Rd. He has undertaken a range of training and has achieved National Vocational Qualification Level 4 and the Registered Managers Award. Staff spoken to were supportive of the manager who was observed interacting appropriately with service users. 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 24 Quality assurance systems in place include monthly visits to the Home by a member of senior management, regular reviews of service users needs and a yearly survey undertaken of service users views. Service user meetings are to commence shortly with the temporary manager explaining the written and pictorial format that is to be used to enable all service users who wish to engage in the meetings. Two comment cards received from relatives indicated that they were very satisfied and “impressed by the care my relative receives in the Home”. Copies of the Organisations policies and procedures many of which have recently been updated to reflect the new Providers are held in the office with staff indicating they had seen and were kept updated as to any changes by the Home’s manager. Appropriate systems are in place to ensure that health and safety practices and procedures are up to date and well maintained. Information supplied in the pre inspection questionnaire indicated that equipment and systems in the home are regularly serviced and well maintained. Risk assessments have been undertaken as to the support required by service users in the event of a fire evacuation in the Home with a demonstration that staff were clear as to their role and responsibilities during a fire drill that was held during the inspection. 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 25 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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 26 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 YA34 Regulation 19 Schedule 2 4 Requirement The Registered Provider must ensure all information and documents in respect of persons working in the Home are available for inspection. The Registered Provider must ensure the Home’s Statement Of Purpose and individual Service User Guides are updated and reflect service provision. Timescale for action 30/10/06 2. YA1 30/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 30 Church Road DS0000067289.V311862.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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