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Inspection on 20/09/07 for 34 Elsee Road

Also see our care home review for 34 Elsee Road for more information

This inspection was carried out on 20th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home consistently meets the key national minimum standards ensuring positive outcomes for the people who live there. The home presented with a very relaxed atmosphere. Staff appeared confident and competent in their roles, and were careful to ensure that peoples diverse needs and wants were met. Peoples care plans reflect their assessed needs. They are detailed and informative ensuring that staff are able to provide appropriate support. Similarly risk assessments enable people to take meaningful risks in a safe manner. People are actively supported to make decisions about their lives both on a daily and more long term basis by staff. The people living in this home do not attend formal day services such as day centres. Instead they are supported to participate in their interests, hobbies, chosen college courses and leisure pursuits, as well as with planning holidays. These are varied and reflective of individual likes and dislikes. The involvement of families and friends is important to people, and is encouraged by the home. A clean, tidy, well stocked kitchen enables people to choose from a range of meal options. Support and encouragement with healthy eating is provided. All three people living in the home on a permanent basis are generally independent when it comes to personal care, however staff work with them to ensure that their individual personal care needs are met sensitively and discreetly in line with their assessed needs if requested. Respite guests also have their personal care needs recorded. These are also met discreetly and with sensitivity as required. Health and wellbeing is also promoted via attendance at routine and more specialized healthcare appointments as necessary. Medication is managed safely on people`s behalf, however support and encouragement is provided to one person to enable them to self administer their medication. The home has both a complaints policy and an adult protection policy in place. Complaints received were dealt with appropriately. People living in the service were happy with the outcome of any complaints they had made. Staff were aware of their responsibilities regarding adult abuse. The home presented as comfortable and clean with no offensive odours apparent. It was decorated nicely, if a little dark in the hallways and on the landings, with good quality furniture and soft furnishings throughout. Staff numbers were satisfactory. Training undertaken by the staff team ensures that a competent and sufficiently knowledgeable team supports the people who live in the home. Management systems in place appear robust. The quality of the service is monitored regularly, and the use of formal systems to test the quality provided ensure that the people living in the home are at the forefront of service development. Health and safety is managed effectively.

What has improved since the last inspection?

Although no requirements were made at the last inspection of this service considerable work has been undertaken to update and improve the care plans of the people living in the home. The dining room has been decorated and new modern dining furniture has been purchased.

What the care home could do better:

No requirements have been made at this inspection.

CARE HOME ADULTS 18-65 34 Elsee Road 34 Elsee Road Rugby Warwickshire CV21 3BA Lead Inspector Justine Poulton Key Unannounced Inspection 20th September 2007 14:00 34 Elsee Road DS0000004287.V338325.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 34 Elsee Road DS0000004287.V338325.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. 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 34 Elsee Road Address 34 Elsee Road Rugby Warwickshire CV21 3BA 01788 547781 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) New Directions (Rugby) Ltd Mrs Emma Daffey Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th June 2006 Brief Description of the Service: Elsee Road is a large terraced Victorian house providing a permanent home for three people with learning disabilities and respite stays for up to three people at any one time. The home is near the centre of town. There is no parking at the home as the road has double yellow lines. Residents permit parking is available. Care staff support people at all times when they are at home. Although people may attend day care services for some or all of the week staffing is provided in such as way as to ensure that they are able to remain at home if they choose. The house is one of four services operated by New Directions (Rugby) Ltd that provides residential care for people in Rugby. Information regarding the current level of charges was not available at this inspection. 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first key inspection in relation to Inspecting for Better Lives. It was carried out to establish the outcomes for people living in the home, and to confirm whether they are protected from harm. Identified key standards were looked at, along with a review of the organisations progress towards meeting any requirements made at the previous inspection of this service. The pre fieldwork inspection record was completed, as well as a site visit to the home, during which time staff, people living in the home and the acting manager were spoken with. A completed annual quality assurance assessment was received from the service prior to the inspection along with six completed surveys from relatives, people using the service and associated healthcare professionals. Three people were identified for close examination by reading their care plans, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’ where evidence is matched to outcomes for service users. Records, policies and procedures were examined and the environment was looked at. All of the people living in or visiting the home for respite were at home for all or part of the inspection. The inspector would like to thank the service users, acting manager and staff for their hospitality and co-operation during the inspection. What the service does well: The home consistently meets the key national minimum standards ensuring positive outcomes for the people who live there. The home presented with a very relaxed atmosphere. Staff appeared confident and competent in their roles, and were careful to ensure that peoples diverse needs and wants were met. Peoples care plans reflect their assessed needs. They are detailed and informative ensuring that staff are able to provide appropriate support. Similarly risk assessments enable people to take meaningful risks in a safe manner. People are actively supported to make decisions about their lives both on a daily and more long term basis by staff. The people living in this home do not attend formal day services such as day centres. Instead they are supported to participate in their interests, hobbies, chosen college courses and leisure pursuits, as well as with planning holidays. These are varied and reflective of individual likes and dislikes. The involvement of families and friends is important to people, and is encouraged by the home. A clean, tidy, well stocked kitchen enables people to choose from a range of meal options. Support and encouragement with healthy eating is provided. 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 6 All three people living in the home on a permanent basis are generally independent when it comes to personal care, however staff work with them to ensure that their individual personal care needs are met sensitively and discreetly in line with their assessed needs if requested. Respite guests also have their personal care needs recorded. These are also met discreetly and with sensitivity as required. Health and wellbeing is also promoted via attendance at routine and more specialized healthcare appointments as necessary. Medication is managed safely on people’s behalf, however support and encouragement is provided to one person to enable them to self administer their medication. The home has both a complaints policy and an adult protection policy in place. Complaints received were dealt with appropriately. People living in the service were happy with the outcome of any complaints they had made. Staff were aware of their responsibilities regarding adult abuse. The home presented as comfortable and clean with no offensive odours apparent. It was decorated nicely, if a little dark in the hallways and on the landings, with good quality furniture and soft furnishings throughout. Staff numbers were satisfactory. Training undertaken by the staff team ensures that a competent and sufficiently knowledgeable team supports the people who live in the home. Management systems in place appear robust. The quality of the service is monitored regularly, and the use of formal systems to test the quality provided ensure that the people living in the home are at the forefront of service development. Health and safety is managed effectively. 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. The summary of this inspection report can be made available in other formats on request. 34 Elsee Road DS0000004287.V338325.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 34 Elsee Road DS0000004287.V338325.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): x x EVIDENCE: Three people live in the home on a permanent basis, and have done for a number of years. Similarly there is a stable group of six respite guests that use the home throughout the year, all of whom have done so for some considerable time, therefore key standard 2 was deemed to be not appropriate on this occasion. 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. A clear, consistent care planning system provides staff with the information they need to satisfactorily meet people’s individual needs. They ensure that people are able to make decisions about their lives as appropriate. People are supported to take reasonable risks based on effective risk management strategies that are agreed and recorded in individual care plans. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person has a well ordered and easy to use care plan in place. Two of these were looked at for case tracking purposes, one belonging to a person who lives in the home on a permanent basis, and one belonging to a person who was arriving for a respite visit on the day of the inspection. 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 10 Each of the plans looked at had a photograph of the individual as well as photos of their keyworker and the manager in place. The plans were detailed and informative and covered all applicable aspects of each person’s life. Information was available within one plan that confirmed that it was reviewed on a six monthly basis, whilst in the second plan looked at information update forms completed by parents or carers were available for each respite visit. Staff spoken with said that these forms are sent out prior to the visit commencing, and are returned when the person arrives for their stay. By doing this the information for respite guests is reviewed and updated as necessary for each visit. The acting manager also said that an annual more formal review for respite guests is undertaken. Information to confirm this was also available in the care plan looked at. Within the care plans looked at were comprehensive risk assessments that covered areas such as self medication, the use of cleaning products, kitchen safety, fire safety and hygiene control. The levels of risk were clearly detailed along with the measures and controls in place to reduce the identified risk. These ensure that people are able to participate in their chosen activities safely. The people who live in this home are all able to make decisions about their lives for themselves, with the staff providing discreet support if requested. In conversation one person was keen to talk about the cruise she had chosen to go on for her holiday, whilst another explained how he chose to spend his time during the day. Meals, activities and style of dress were all areas it was noted people made choices about during the inspection. 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. The people who live in and visit this home continue to have the opportunity to live ordinary and meaningful lives within the community in which they live. Support to maintain and develop family links and friendships is available. A varied selection of food is available that meets service user’s dietary needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All three of the people that live in the home on a permanent basis have activities, hobbies and interests that enable them to make use of local community facilities such as the local college, community placement unit, and a local lunch club. In addition, a day care service is available from another of the organisations homes should people wish to attend. One of the two people 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 12 chosen for case tracking said in conversation that he enjoys the IT and computer courses that he attends during the week. On a more social level opportunities for people to go bowling, out for meals, shopping, to the cinema and to local pubs are routinely offered amongst others. Two of the three people that were at home for part of the inspection talked about the Mediterranean cruise they were looking forward to in the near future that they had chosen together. Staff at the home said that they ensure that the people who visit for respite continue with their usual daily placements and activities. Also, as it is a small group of people who use the service throughout the year, they generally get on well with the people who live in the home, and enjoy participating in all of the social activities offered. This was confirmed in conversation with one person who was staying for a respite visit at the time of the inspection. Surveys received from people who both live in and visit the home for respite indicated that they were all able to participate in activities of their choosing, and were happy with the lifestyle the service offered. Information was available to confirm that relationships between the people living in the home and their families and friends continue to be important, with staff providing support to maintain these relationships as much or as little as people want. Contact with family members were recorded within their diaries. At the time of the inspection one person was on holiday with their family. The home is domestic in size and nature. As such any routines that are in place continue to be imposed by the people living there. During the inspection the atmosphere was relaxed, with jovial bantering and conversation taking place. The home has a kitchen and a separate dining room. The kitchen was clean and tidy with domestic style equipment available for people to use. Food stocks were plentiful, and there were lots of fresh fruit and vegetables available. The staff member on duty said that he tends to shop for food as it is needed to ensure that it is fresh, however he was aware that other staff members shop differently. It was noted that people’s individual food likes and dislikes were available in the kitchen. Health checks pertinent to the kitchen and food hygiene were also available. 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. The Care plan programmes in place ensure that personal support is consistent, reliable and responsive to peoples needs. The healthcare needs of people are assessed and recognised with evidence of specialist services being readily available to them. Medication policies and procedures ensure that medication is managed safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The three people that live in the home on a permanent basis have limited personal care needs, as they are relatively independent in that area. Any personal support that is required was clearly detailed within the care plans looked at however. Similarly the personal care and support needs of those people that visit the home as respite guests were clearly detailed in the care plans looked at. 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 14 Information was available to confirm that people continue to be offered routine healthcare appointments such as the dentist, optician and chiropodist at the recommended intervals. Information was also available to demonstrate that more specialised healthcare needs are addressed as appropriate. Staff spoken with said that the parents and carers of the respite guests that visit the home look after their healthcare needs, but that support is offered if an appointment falls during a respite visit, or if someone is taken ill whilst visiting the home. Medication continues to be supplied to the home by Boots in blister packs that are accompanied by medication administration records (MAR). The home stores medication in a locked filing cabinet in the quiet lounge / office. Each person has their photograph attached to their ‘MAR’ chart. Staff on duty said that the house leader is responsible for booking in, reordering and returning medication. They also said that all of the staff receive training in medication administration before they are allowed to undertake this practice. This was confirmed by the staff training records looked at. One person continues to administer their own medication, with a risk assessment was in place. Staff spoken with were able to describe the procedure they use to ensure that this continues to be managed safely, whilst enabling the person to retain control of their medication. People visiting the home for respite bring their medication with them. This is checked in at the beginning of their visit, and checked out at the end of their visit to ensure that it tallies. It is stored, administered and managed in the same manner as the medication for the people who live in the home on a permanent basis. 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. The home has a satisfactory complaints system and can evidence that people’s views are listened to and acted upon. There are policies and procedures in place for the protection of people from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has the organisations policy on complaints in place. There was also an accessible complaints procedure that utilised pictures and symbols available for the people living in and visiting the home. A complaints log was in place in which five complaints were logged along with the records of the investigations undertaken and the outcome. It was noted that two of these complaints were form people living in the service. They both had positive outcomes for the people who had made them. An organisational policy on protection from abuse was also available within the home. Staff spoken with were able to explain what they would do if they suspected abuse or if any was disclosed to them. They also advised that they had received training in this area. Training records looked at demonstrated that training in the protection of vulnerable adults had been provided during the 12 months prior to this inspection. The acting manager confirmed that 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 16 there have been no allegations or suspicions of abuse made in the previous 12 months. 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. The appearance of this home continues to create a comfortable and homely environment for the people living there. The home remains clean and hygienic with policies in place to ensure that the risk of infection is minimal. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is a large terraced Victorian house providing a permanent home for three people with learning disabilities over three floors. There is also the provision to provide respite visits for up to three people at a time. At the time of the inspection there was one person staying at the home for respite, with another arriving during the afternoon. The home is near the centre of town. 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 18 There is no parking at the home as the road has double yellow lines. Residents permit parking is available. Communal accommodation comprising of a pleasant lounge, dining room, quiet room/office and kitchen is available on the ground floor along with the laundry facility and a toilet. Bedroom accommodation along with two bathrooms and an additional toilet is situated on the first and second floors, as is staff sleep in room. Furniture and soft furnishings in the communal areas of the home were of good quality, and the décor was modern and fresh. It was noted that the dining room had been recently redecorated, and new modern dining furniture purchased. Two bedrooms were seen during the inspection. Both were decorated and furnished to individual tastes with plenty of personalisation in the form of ornaments, pictures and soft toys. The hallways and landings were very dark, due to the nature of the décor, however it is noted that this was mentioned in the regulation 26 report received recently, and is going to be addressed. A policy on infection control is available within the home along with a procedure for the prevention of infection and cross contamination. This ensures that practices are safe in relation to the transportation of dirty laundry through the kitchen to the utility area. On the day of the inspection the home was clean and tidy with no offensive odours apparent. 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. People benefit from a well-trained, and enthusiastic staff team who work towards common goals. People are supported and protected by the homes recruitment policy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The annual quality assurance assessment provided by the home before the inspection indicates that the home continues to employ four staff, which consist of a house leader, a shift leader and 2 care assistants. The home is staffed on a 24 hour basis by one person per shift. Staff spoken with did indicate that this can be increased for planned activities if necessary. 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 20 Staff records were available within the home to confirm that safe recruitment procedures are undertaken to ensure that people are safeguarded. An application form, two written references, a criminal records bureau check (CRB) and terms and conditions of employment were available for all staff. The organisation places great store on valuing it’s staff team by providing consistent training to enable them to do their jobs to the best of their abilities. Each staff member had an individual training record available within the home. Those looked at confirmed that all of the mandatory subjects such as first aid, food hygiene and fire safety were all up to date. All four staff have completed the Learning Disability Awards Framework induction programme. In addition training in subjects such as mental health, makaton, dementia and epilepsy are also provided for staff. One staff member advised that he had very nearly completed his NVQ III qualification. 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. The temporary leadership, guidance and direction to staff ensures people receive consistent quality care and support. People are consulted about the quality of life within the home. Health and safety is managed appropriately This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection the manager and deputy manager for the home were both on maternity leave. An acting manager, who appeared competent and knowledgeable about the home and the people living in and visiting it, was undertaking the management of the service. The acting manager also has management responsibility for another home within the organisation, which is where the main office base is. In discussion he said that said that he spends 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 22 time in the home proportionate to the number of people that live there, and visits a minimum of three times per week. The day to day management of the home is delegated to the house leader who is supervised by the manager on a regular basis. There is also a shift leader in post who supports the house leader and the care staff. Staff spoken with said that the acting manager is always available via telephone and will visit the service if requested. The home undertakes annual quality assessments via the use of questionnaires that are sent to the people that live there and their relatives. Copies of completed questionnaires for 2007 were seen. The acting manager said that once they had all been received they were collated and a report and action plan produced based on the information obtained. In addition, the quality of the service provided was monitored via regular staff meetings, regular house meetings and complaints. No regulation 26 visit had been undertaken since January 2007. This was discussed, and it would seem that it was due to a misunderstanding of the information on our website. This has since been clarified and these visits have recommenced. Evidence was available to demonstrate that the health and safety of people living in the home, staff and visitors is maintained. A sample of health and safety checks was taken, which included fire drills, portable appliance testing, electrical installation testing and fire alarm points, all of which were up to date. 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 x 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 4 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 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 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 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 24 NO 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. Standard Regulation Requirement Timescale for action 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 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 34 Elsee Road DS0000004287.V338325.R01.S.doc Version 5.2 Page 26 - 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!