Inspection on 22/02/07 for 31 Whitwell Road

This inspection was carried out on 22nd February 2007.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

31 Whitwell Road 16/03/09

31 Whitwell Road 23/06/08

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 31 Whitwell Road Southsea Hampshire PO4 0QP Lead Inspector Liz Normanton Unannounced Inspection 22nd February 2007 10:00 31 Whitwell Road DS0000067311.V326868.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 31 Whitwell Road DS0000067311.V326868.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. 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 31 Whitwell Road Address Southsea Hampshire PO4 0QP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 02392 793941 02392 341476 Bayrose Limited Mrs Sheila Anne Musselwhite Care Home 9 Category(ies) of Learning disability (9) registration, with number of places 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users only to be admitted between 18 and 55 years of age Date of last inspection 20/12/05 Brief Description of the Service: 31 Whitwell Rd is one of a number of diverse services run by Sheila Musslewhite of People First to provide support services to adults with learning disabilities. The home accommodates nine service users and is situated in a residential area of Southsea close to the seafront and local amenities. Accommodation is organised across three floors, with an office in the basement. There is a small, enclosed garden with a conservatory leading to the communal dining room and kitchen. There is a lounge and one of the 2 double bedrooms on the ground floor. The other bedrooms are sited on the upper 2 floors. There are 2 communal bathrooms and a statement in the service user guide for the home identifying this shortfall in provision. The home aims to provide residential services that promote the independence of the service users, in line with current best practice. Weekly Fees:£324.45 - £983.57 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken on 22/02/07 and focussed on what the Commission considers to be core standards for a care home for younger adults as defined in the Department of Health (DOH) National Minimum Standards. Information was gathered from a variety of sources, which included data being sent to the Commission prior to the site visit, discussion with three service users, written feedback from four service users, feedback from seven relatives two befrienders, discussion with three staff, a care manager and the acting manager. Three staff files and three service users’ files were also viewed. This information was then triangulated to access outcomes for people living at the home. The overall outcome was that the residents and relatives are very satisfied with the service provided at the home. Three requirements have been made at this inspection. What the service does well: What has improved since the last inspection? The worn carpets in the hall and staircases have been replaced since the last inspection. An en-suite shower and toilet facility has been fitted to a ground floor double bedroom. 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 31 Whitwell Road DS0000067311.V326868.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 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. The home will not accept prospective service users until it is satisfied that individuals needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no new admissions to the home since the last inspection. There was evidence in a residents file that following referrals from social services the home undertakes a needs assessment of the prospective service user and obtains as much information as possible from other sources. A copy of the care managers care plan and a letter presented by a parent were seen on the file. The needs assessment was comprehensive and included details about next of kin, health needs, challenging behaviour, communication, risks, domestic skills, and basic skills ability, activities and leisure interests. In discussion with the acting manager they reported that a meeting with all parties involved would also be held and if it is agreed that the home can meet an individuals needs they will offer prospective residents a placement on a months trial and then a review would be arranged. As part of the admissions 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 9 process prospective residents are invited to visit the home as often as they would like. 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. The home plans with service users how their needs are to be met and their personal goals are to be achieved. The home promotes the rights of service users to make choices, partake in life decisions, participate in the running of the home, lead full and active lives, in a manner that promote the individuality and rights of residents’. Service users are supported to take risks as part of living a more independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at three residents care plans and found the information in them had been drawn up from the needs assessment. The information supplied was detailed and would instruct carers how to meet an individuals needs and enable them to provide consistency of care. 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 11 Care plans also included aims for the year and what help, support and action were required to enable an individual to attain their goals. There was evidence that care plans are reviewed monthly and also as required. The three care plans viewed were written in the second person and not person centred. In individual discussion with three residents, two demonstrated that they knew about their care plan and were involved in their reviews. In discussion with two staff they reported that they have a key worker responsibility in supporting individual residents and this is to help them to develop a closer relationship and offer individual assistance to the residents. Two of the three residents spoken with knew who their key worker was and found them very helpful. In written feedback from four residents they informed us that they could make choices about what they do on a day-to-day basis. During the course of the inspection visit people were observed making choices about how they occupied themselves, who they spent time with, what to have for lunch. One resident was observed going out in to the community individually in the afternoon. People were observed making their own drinks and helping out in the kitchen. One resident had wanted to give up smoking and details of the support needed were written in their care plan. Details of risk are gathered as part of the needs assessment. The home then undertakes risk assessments on each individual and these detail potential risks and what action should be taken to remove or minimise the risks. We received seven relative/visitor comment cards and two people informed us that they are always consulted about the care of their son or daughter and four people told us they were sometimes consulted about their son or daughters care. One person who was not a relative they said they are not consulted about their friend’s care, which we consider, is appropriate. Two parents made the following comments: “We are very satisfied with the level of care and our son is very happy there.” “ I can think of no adverse comments about 31 Whitwell Road and Mrs Musselwhite is doing a wonderful job.” In discussion with a care manager visiting the home at the inspection visit they reported that they were happy with the care provided to the two clients that they support. 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. Service users participate in their local community, and have access to a range of leisure activities, and other meaningful activities, in and outside of their home. The home promotes the rights of service users, and ensures that they have a diet that meets their needs and wishes in a flexible manner that promotes choice and independence. Service users are encouraged and supported to be as involved in shopping and food preparation as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff support three service users to attended day centre services and one attends college. In discussion with one service user they reported that they would like to work but didn’t know whom to ask. 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 13 Each service user has an annual review of their placement and are able to use this as a forum to discuss education and employment. Service users are supported to maintain interests they had prior to moving in to the home. In discussion with one service user they reported that they go shopping with their befriend every two weeks and they were looking forward to going to a disco at the weekend. They were also excited about going to Butlins on holiday, which is planned in March 2007. They stated that they had been on holiday last year and had really enjoyed it. In written feedback from four service users one told us they go out for walks and go out to visit their friend. In individual discussions with two staff and the acting manager they reported that service users have the opportunity to go out to pubs, cafes, horse riding, swimming and play pool and basketball. Several of the service users have individual befriender who come to the home to support them to go out in to the local and extended community. In written feedback from one befriended they commented that the person they visit is not always ready to go out when they arrive and that one member of staff had once told them it was not their responsibility to get the person ready. Nobody is currently attending any places of worship and the home is not visited by anybody from a religious denomination. In discussion with the acting manager they reported that all service users are included on the electoral register and those with capacity are supported to vote. Service users are supported to maintain family links, staff told us that one service user goes on holiday with their parents every year. In written feedback from four service users one told us they visit a friend and another said they go out with their cousin. Relatives and friends can visit service users at home and information supplied in seven comment cards six people told us they are made welcome at the home with one not feeling that they are made welcome. Service users are involved in the daily routines, one service user was observed laying the tables for lunch and in discussion with two residents they reported that they do the washing up and tidy up after meals and are responsible for cleaning their rooms and doing there laundry. Details of basic living skills and goals are recorded on service users files. 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 14 The staff were observed interacting positively with the service users and during the handover from the morning shift to the afternoon shift it was obvious from discussions that the staff team knew the service users well. In discussion with the staff and acting manager they reported that the menu is planned weekly in consultation with the service users. The home provides a set menu for the teatime meal. If service users do not want what is on offer they are offered an alternative. Breakfast and lunchtime meals are not planned and service users can choose when they want to eat. The teatime meal is usually prepared for 5.00pm but service users can choose to have it later. In discussion with two staff they confirmed that the service users are provided with fresh fruit and vegetables everyday. The lunchtime meal was served at 12.00pm and service users had chosen beans and cheese on toast. It was observed that tureens were put out on to one of the dining tables and service users helped themselves. Those service users who required support at meal times had their meals plated up and food had been cut up for them. In discussion with three service users they reported that the food was good. 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. Staff provide a sensitive and flexible approach in supporting service users with personal care needs. The home is able to meet the emotional and health needs of the service users. The home has tried to demonstrate good practice in providing each resident with their own medication facility, which is held in their rooms. However the homes procedure for dispensing the medication does not comply with The Administration and Control of Medicines in Care Homes and Children’s Services document, produced by the Royal Pharmaceutical Society of great Britain. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at three individual care plans, which clearly identified how each service user needs to be supported in the area of personal and health care. Individuals Care Plans support and promote independence, and also highlighted systems to ensure that health and emotional needs were identified and met by the staff team, or other relevant professionals. 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 16 For those service users who have a single room personal support is provided in private. There was no evidence of screening in shared rooms and the right to privacy may well be being compromised. In discussion with a member of staff they reported that the home has screens but they are not used. No service users spoken with raised the lack of privacy as an issue. In written feedback from four service users they informed us that they could retire and awaken to suit them. Each service user is registered with a general practice and has access to medical care. In discussion with a care manager they reported that they were aware that their client visits the dentist independently and has access to eye care. There was evidence on service users files that people have regular annual health care checks. One service users health had deteriorated in 2005 and they had difficulty with mobility and the home obtained a wheelchair to enable them to continue to go out in to the community. The person has made a recovery and is now able to get about more freely. Each service user has a medication storage facility in their rooms, which are securely locked and the senior staff on duty hold the keys. Medication is received into the home monthly from the chemist and a senior member of staff dispenses a week’s supply into each individual’s dossett boxes. This practice is known as secondary dispensing and should cease as it is regarded as outdated and unsafe practice. The home should seek advice with regards to the appropriate handling and administration of medication. The medication record sheets used by the home are not standard issue and were difficult to follow, however a staff member was able to demonstrate that they knew exactly how to use the record sheets and there was evidence that these sheets had been signed when medication was administered. In discussion with two staff they confirmed that they had received medication training both in house and externally. There was evidence that two service users self medicate however there was only one of these people who had a risk assessment in place. All people responsible for taking their own medication must have a risk assessment. 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. The home ensures that there is a clear and effective complaints procedure which includes the stages and timescales of the process and service users no how to complain. Robust procedures are in place to protect service users from abuse, neglect and self- harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager informed us in the returned pre-inspection questionnaire that there have been no complaints since the last inspection. The home has a complaints procedure which is accessible to service users. Three service users who returned questionnaires told us they knew how to make a complaint with only one being unsure about how to do this. We received eight relative visitor comment cards, which indicated that five of the eight knew about the homes complaints procedure whilst three did not. The home may want to consider making the complaints procedure more easily accessible for visitors. Seven of the people who returned the comment cards told us they had never made a complaint. One parent said, “ I have always been more then happy with the standard of care my daughter gets and I am sure she is very well looked after”. 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 18 In individual discussion with two staff they were able to demonstrate that they knew what to do if a anyone made a complaint. The home has an adult protection procedure and in discussion with two staff they reported that they had read the procedure and were also aware of the homes “whistle- blowing” policy. There have been no adult protection investigations since the last inspection. The two staff spoken with had both been on adult abuse awareness courses. 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. The home provides service users with a homely environment and is kept clean and tidy by the people living there. Attention needs to be paid to the area of prevention of infection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial tour of the home was undertaken which took in all communal areas and two double bedrooms. The home is decorated and maintained to a good standard, in line with the wishes of the resident group. There are three large settees in the lounge, which in the opinion of the inspector did not offer comfortable seating in which service users could sit and relax. This was mentioned to the acting manager who explained the seating had been provided due to continence problems, which had lead to other 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 20 furnishings being damaged in the past. The home would be advised to consider replacing this furniture with specialist seating suitable for people with continence problems. In discussion with three service users they confirmed that they were consulted about the choice of décor throughout their home, and in their individual rooms. Investment into the physical environment of the home is ongoing. The shared bedrooms would benefit from provision of separate sinks, and/or en suite WCs. The plans to develop an en-suite facility with shower in the ground floor bedroom have been completed, and this has improved the ratio of toilet/bathrooms to service users. At the time of the visit the home was well presented, clean and bright, providing a homely environment to the service users. Staff members continue to support service users in keeping their home clean and tidy. The worn carpets in the communal hall and stair areas have been replaced with laminate flooring. Cotton hand towels were being used in all communal W/Cs, this practice could lead to spread of infection and the home should take action to prevent the spread of infection. Staff, are provided with protective aprons and gloves for the purpose of meeting personal care needs. All staff had been trained in infection control. In written feedback from four service users they have told us that the home is always kept clean and tidy. 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 35 Quality in this outcome area is good. Service users are supported and protected by the home’s recruitment policy and practices. Appropriately trained staff meets the individual and joint needs of service user’s. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In discussion with two staff they reported that they had completed an application form and provided identification, 2 references and completed a Criminal Record Disclosure form as part of their recruitment process. We looked at three staff files and found them to contain the relevant evidence of recruitment documentation as required by legislation, which demonstrated that the home has a robust recruitment procedure. The two staff spoken with confirmed that they undertook induction training when they took up their employment and that they shadowed other staff on duty for up to three weeks. 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 22 Information supplied on the pre-inspection questionnaire submitted prior to the inspection indicated that staff had undertaken training relevant to their roles and responsibilities over the past twelve months. Training included, fire safety, first aid, counselling, managing behaviour, bereavement. Further training is planned throughout 2007, which includes person centred planning. In individual discussion with two staff they confirmed that they had undertaken training whilst being employed by People First. Evidence of training certificates were seen in two staff files. The manager keeps a training record for each member of staff. 31 Whitwell Road DS0000067311.V326868.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39, & 42 Quality in this outcome area is good. Service users will benefit from a well managed home. There will be quality assurance systems in place. The health, safety and welfare of the service users is generally protected and promoted by the home however there is room for improvement in the area of storing COSHH materials . This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of this inspection the registered manager was not present in the home due to having had an accident, which has left them unable to be physically present in the home however they are providing long arm support to the staff and acting manager. The inspector was assisted to undertake the inspection by the acting manager. The acting manager reported that they are 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 24 providing 25hrs managerial cover a week in the absence of Sheila Musselwhite and are also on call. Staff working in the home were happy with the managerial arrangements in Sheila’s absence and service users made no comment. With regards to quality assurance the acting manager reported that the home seeks the views of the service users through annual questionnaires. Each service user has a multi-disiplinery review every year in which the placement is discussed and issues can be raised. Service user meetings are usually conducted in an informal way and the matters discussed are recorded. The manager reviews and updates policies and procedures in line with changes in legislation and good practice recommendations from the Department of Health. The manager ensures that staff adhere to heath and safety procedures within the home buy setting an example and providing mandatory training which includes health & safety in the workplace, food hygiene, manual handling, fire safety and infection control. The home does not have locked storage facility for substances considered hazardous to health (COSHH). COSHH products are stored in cupboards in the laundry, which are easily accessible. A number of COSHH products were seen in a communal bathroom and although they had been stored high on a shelf out of reach they were not stored in accordance with Control Of Substances Hazardous to Health regulations (COSSH) 1999. In discussion with two staff they demonstrated that they knew the home’s fire procedures and would know what action to take in the event of a fire. The home has a hard-wired fire alarm, linked to smoke detection throughout the home. Fire systems are routinely tested every week and records maintained. The home has other fire prevention apparatus that is also tested and maintained to the makers’ recommendations, and staff members confirmed that they received regular fire training. The manager ensures that boilers and central heating systems are serviced regularly. Portable electrical appliances are checked annually. All accidents, injuries and illness or communicable diseases are recorded and those of a serious nature are reported to CSCI. 31 Whitwell Road DS0000067311.V326868.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 x 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 2 STAFFING Standard No Score 31 x 32 x 33 x 34 3 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 2 x 3 x 3 x x 2 x 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 YA20 Regulation 13 (2) Requirement Timescale for action 11/05/07 2. 3. YA30 YA42 13 (3) 13 (3) & 13 (4) (a) In the interests of safe medication handling all medication must be administered directly from the original container to the service user, and not placed into a secondary container for later administration by another person. Advice must be taken from the pharmacist. Action must be taken to ensure 11/05/07 the risk of cross infection is minimised. You are required to store 11/05/07 cleaning materials in accordance with Control of Substances Hazardous to Health regulations (COSSH) 1999. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA24 Good Practice Recommendations Service users would benefit from the purchase of purpose made furniture in the lounge to provide more comfortable DS0000067311.V326868.R01.S.doc Version 5.2 Page 27 31 Whitwell Road 2 YA18 seating. Those service users that share a bedroom would benefit from the use of screens to provide them with privacy. 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 31 Whitwell Road DS0000067311.V326868.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!