Inspection on 08/01/07 for 40 Cody Road

This inspection was carried out on 8th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

40 Cody Road 14/11/05

40 Cody Road 24/01/05

40 Cody Road 27/07/04

40 Cody Road 27/01/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 40 Cody Road Cove Farnborough Hampshire GU14 0DE Lead Inspector Tracey Box Unannounced Inspection 8th January 2007 09:30 40 Cody Road DS0000011560.V320364.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 40 Cody Road DS0000011560.V320364.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. 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 40 Cody Road Address Cove Farnborough Hampshire GU14 0DE 01252 372057 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) sarah.pilgrim@new-support.org.uk www.new-support.org.uk New Support Options Limited Mrs Sarah Jane Pilgrim Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (5) of places 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: 40 Cody Road is a purpose built bungalow offering accommodation for up to five persons with a learning disability all accommodated in their own bedroom. The home which is managed by New Support Options Ltd. who are also responsible for operating similar services located in the South of England, is situated close to Farnborough town centre with access to local amenities and transport. The nearby towns of Aldershot, Camberley, Fleet, and Farnham are all easily accessed using either public or the homes own vehicle. 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The opportunity was taken to look around the home, view records and procedures. Due to the nature of the service user’s disabilities it was quite difficult to talk to everyone living at the home, but observation enabled the inspector to gain a better understanding of how the needs of service users were being met. The inspector spoke with one social worker who visited a service users to complete their annual review of care. The staff on duty during this visit felt they were supported to do their job. The commission has received information from the home prior to this visit, This has provided additional evidence to show how the home are meeting the key National Minimum Standards. The fees for the home range between individuals from £1,126.19 to £1,149.28 per week. What the service does well: What has improved since the last inspection? The manager has re-assessed all service users, as requested following the last inspection, and records showed service users representatives were consulted in the assessment process. The home use photographs and pictures to ensure individuals have the information they need to enable them to choose what activities they wish to 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 6 participate in, colour schemes for re decoration, what they prefer to eat each day. A notice board in the kitchen has photographs of the members of staff who will be on duty during the day and night. Another board displays pictures of the activities each individual has chosen for the week, and what they have chosen to eat for each meal. A new fence panel has been replaced in the garden, and the home employ a gardener. The staff team are working with service users and their relatives to develop individual’s Person Centred Plans (PCP). Four bedrooms have been redecorated. 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. 40 Cody Road DS0000011560.V320364.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 40 Cody Road DS0000011560.V320364.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 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefited from having their needs and aspirations assessed on a regular basis. Each service user has a signed statement of terms and conditions. EVIDENCE: The manager has re-assessed all service users who had not previously been assessed, as requested following the last inspection. Records showed service user’s representatives were consulted in the assessment process. Since the last inspection one service user has moved to the home following a comprehensive pre admission assessment completed by the manager, there was also documents to show that a physiotherapist, occupational therapist and a representative from the challenging behaviour team, were part of the assessment. Evidence from service users’ files showed that they had all had care management assessments prior to moving into the home. In addition, the home undertook further assessments of service users’ needs on a regular basis. Assessments were comprehensive and addressed a full range of need areas, including psychological and mental health needs and communication. 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 9 The manger said at this stage of the assessment process it is very important to find out how the individual prefers to communicate, as this will identify if the staff need further training to meet the individual’s needs. The manager said she and a ‘link worker’ complete pre admission assessments and gather as much information as possible from previous place of residence, families, healthcare professionals, friends, staff and care managers. Records of one recently admitted service user showed he spent one day at the home as part of the assessment process, he was fully supported by his keyworker of his previous residence, and was involved in the daily activities of the home and spent time with other service users who live in the home and the staff who work here. One member of staff said she knew she might be his link worker if he wanted her to be, so they spent time together getting to know each other. Unfortunately the service user did not want to speck to the inspector, but interacted well with staff and service users who were at the home during this visit, and it appeared he had settled in well. Individual Care Plans on file clearly related to the issues identified through the assessment process, including possible trigger causes of epileptic seizure, what staff need to be aware of and agreed steps to take for recovery following a seizure. Individual needs and aspirations are discussed at their annual reviews, records showed these occurred and involved social services and the service users families if they wished. On the day of this visit, the inspector spoke with one social worker who visited a service user to complete their annual review. The social worker said he had only recently become the service users social worker, and did not know much about the home, other than colleagues had told him that the home provide good care and staff act as advocates on service users behalf, for example, the service user wanted money to buy a wide screen television, staff explained how this would improve the quality of life for this service user, the social worker said he would need to follow procedures to see if this will be possible. Statements of terms and conditions have been designed in picture format to meet individual’s needs, and had been signed by either the home manager or the provider’s chief executive. The manager said the terms and conditions are explained to service users and their representatives, however service users who currently live at the home do not have the ability to sign contracts, and the manager said care managers will not sign them and it is difficult to obtain relatives signatures. The manager said she will discuss this issue with her manager to ensure either service users or their representatives sign the terms and conditions to show they agree with them. Two service users statement of terms and conditions were looked at, they included details of additional costs the service user would be expected to pay for, for example toiletries, gifts for families/friends etc. 40 Cody Road DS0000011560.V320364.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. This judgement has been made using available evidence including a visit to this service. Service user’s or their representatives are involved in the preparing and reviewing of their care plans. Service users are fully supported to make decisions in all areas of their lives. Risk assessments are in place to enable service users to take risks as part of an independent lifestyle. EVIDENCE: Care plans seen were being developed further to be more person centred, and included information about how the individual wishes to be supported in their daily activities, including a daily routine from the moment they want to get up, to the support they need when they want to go to bed, which included any specialist equipment such as wheelchair, hoist, bath and bed. Other information included personal history, religious beliefs, family relationships, dreams and wishes for the future, details of friends and important people in service users lives. The care plans included photographs and pictures to meet 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 11 individual’s needs, for example, a section for communication shows pictures and illustration of how a person communicates ‘yes’ and ‘no. All care plans seen had been reviewed monthly, with the individual or their representative being involved in the preparation. The home operates a link worker system, which means each service user has a named staff member they work with to arrange reviews, revise care plans, ensure service user’s needs are being met, plan things to achieve and work towards, and the link worker will sometimes act as a service users advocate in certain situations. Staff said this system helps relatives too, as they know who to contact. The home use photographs and pictures to ensure service users have the information they need to enable them to make choices. A notice board in the kitchen has photographs and pictures to display ‘a flow of the day’, which includes the time of day the service user has chosen to wake up, what they have chosen to eat for all meals, which activities each individual has chosen to do, and what time they wish to go to bed. Staff said they will be working with service users to develop their ‘circle of friends’ to show people who are important in their lives. Staff were aware of how to access advocacy services should any service user need to, however at present the manager said no service user has expressed a wish to speak with an advocate. Staff spoken with were able to demonstrate an understanding of the need to support service users to make their own decisions, this is also covered during new staff induction. Staff said it is important to offer choices to individual’s to enable them to decide what they want, one member of staff said ‘I can tell a lot about what people think by their body language and facial expressions, we try to enable many different opportunities for service users, and their reactions inform us of what they think.’ The Statement of Purpose and Service User Guide were clear about the rules in the home and each service user had a copy. These also contained information on who service users could talk to if they were unhappy about any aspect of the home. Both documents were produced in an easily accessible format for service users who had some difficulty reading. Risk assessments were seen for two service users and covered moving and handling (which included wheelchair, hoist and sling use) and bathing. The manager said no other risks had been identified. 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is good at providing support for individuals to take part in age appropriate, peer and cultural activities with the home and access to the local community. They encourage appropriate personal, family and other relationships whilst respecting and empowering individuals rights and dignity. Service users are offered plenty of fresh food with lots of choices to enable a balanced and healthy diet. EVIDENCE: Individual’s preferences regarding activities and cultural beliefs are recorded in their care plans, records of daily activities are recorded in an activities diary, these ranged from attending physiotherapy at a day centre called ‘Parity’, cooking, shopping, visiting family and participating in activities of individual interests, such as listening to music and completing puzzles. A weekly activities timetable showed all of the fore mentioned. 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 13 One member of staff some staff were able to use their cars to transport service users to places. The inspector saw the visitors book which detailed many visits by relatives and health care professionals and social workers. On the day of the inspection service users were participating in various activities within the home, from watching tv, listening to music, and completing a puzzle with staff verbal assistance, all service users appeared content spending time with staff. The manager said one service user expressed a wish to visit his mother prior to Christmas, staff supported him to do this, by arranging the visit with his mother, and arranging additional staff to drive and accompany the service user. The notice board in the kitchen showed pictures and times of the day for various activities each service user has chosen to do, staff said this is devised with the service user at the weekend, however an activity is altered if the service user wishes. Staff ensure the board details exactly what the service user wishes to keep them informed of what is happening during the day and week. The inspector saw the menu displayed for meals on the day, it showed pictures of the food which service users had chosen, the staff use a variety of pictures of all foods imaginable, which enable service users to choose exactly what they want to eat. The inspector witnessed lunch time meal which was a snack as service users prefer to eat their main meal in the evening, care plans reflect this. The cupboards, fridge and freezer were stocked with foods which would enable choice and variety. A member of staff said a record of all food eaten is kept to ensure service users eat a balanced diet, and that the wide variety of pictures has encouraged service users to eat new and exotic foods. 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive support in a way that they prefer, care plans are reviewed to ensure this information is current. Staff follow the home’s procedures to ensure Service user’s physical and emotional health needs are met. Service users are protected by staff who receive appropriate training for the safe administration of medication. 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 15 EVIDENCE: Service users are able to access all parts of the home and gardens as they have all been assessed and if appropriate provided with personal mobility/living aids following consultation with external health care specialists. Currently special chairs, beds, baths, grab rails and hoists are available. Staff said if any personal care is given or if a visiting health care professional needs to examine a service users, this takes place in the privacy of the service user’s own room (the doors to which have all been fitted with a lock . Records seen confirmed service users are not only free to choose their own doctor and source of any other personal services eg. dentist ,chiropodist etc. but that a wide range of health care professionals are consulted to ensure their health care needs are met, for example a speech and language therapist assessed a service user who was coughing after drinking fluids, the therapist suggested a way to minimise further occurrences, and staff support the service user with this, and the inspector witnessed the service user did not cough after drinks he had during the visit. Records seen confirmed consultation with doctors, district nurses, care managers, continence advisors, epilepsy nurse, chiropodist, optician, physiotherapists etc. The manager said other specialists are consulted as required. All drugs were securely stored and administered in accordance with an in house and corporate medication policy and procedure. Records of administration and disposal of unwanted drugs and medicines seen were available complete and accurate. A pharmacist via a monitored dosage system dispenses all drugs administered in the home. At the time of this visit, the manager said no service users self-medicates their medication due to the individual’s needs. Records seen confirmed all staff administering drugs and medicines had received training. The manager said new staff receive training and ‘shadow’ trained staff to witness the medication procedure prior to being assessed by the manager before completing medication. 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users may benefit from the complaints procedure being made available in picture format. Arrangements for protecting service users are good. EVIDENCE: The home’s complaints procedure included details on who to contact should anyone need to raise any issue of concern or complaint, the procedure also included contact details of The Commission for Social Care inspection (C.S.C.I.) Due to communication difficulties the inspector was not able to establish whether service users understood the complaints procedure, and recommended to the manager that service users appear to respond to picture format (as care plan, and menu etc) therefore service users may benefit from a pictorial complaints procedure. The manager said she has drafted one prior to this visit, and it is with her manager. A record of complaints indicated no complaints had been received since the last inspection. The staff said that they receive training in the protection of vulnerable adults from abuse, certificates confirmed this. There has been no allegation of abuse at this home. The home has a copy of the Hampshire County Council ‘Protection of Vulnerable Adults’ policy and procedure that is available in the home’s office. 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 17 The inspector spoke with the social worker who was looking at the financial records of one service users who lives at the home, he said the cash held equated to the amount recorded for the individual. The manager confirmed the home have a ‘social leisure’ budget, which is used to pay for day trips. Money is raised by fundraising by the home. 40 Cody Road DS0000011560.V320364.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A safe, well maintained, clean and suitably furnished home and accessible garden is provided for service users which meets their needs. EVIDENCE: The home is well maintained with ample communal space, the secure garden appeared well maintained and is accessible to service users. The manager said the home has a five year maintenance programme, since the last inspection a new fence panel has been replaced in the garden and four service user’s bedrooms have been redecorated. The manager explained service users are encouraged choose the colour scheme for their bedrooms and furnish the room with personal belongings, furniture and pictures to make it feel like home. 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 19 The inspector saw communal areas were clean, bright and warm, furnished to the individuals taste and personalised with photographs of individuals and staff participating in various activities. The home appeared clean, no offensive odours were detected. Staff said they have completed infection control training, and were aware of the home’s policies and procedures of hygiene issues. The inspector saw records of staff training and the member of staff who was cooking confirmed they were up to date with food hygiene training. The home’s radiators and pipe work are safe ensuring that all potential hot surfaces are kept to low temperature. The washing fitted had a high temperature programme (in excess of 65 degrees c) and sluicing mode. 40 Cody Road DS0000011560.V320364.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are met by sufficient numbers of well trained and supported staff who are recruited and selected using a procedure designed to protect all service users. EVIDENCE: Staff told the inspector they feel they have adequate training to enable them to do their job properly. Records of staff training reflect this and show staff have received training in adult protection, health and safety, manual handling, first aid, food hygiene, epilepsy, infection control, person centred planning, autism, fire awareness. The manager confirmed seven out of eleven staff have received a National Vocational Qualification (NVQ ) level 2 or above. Staff said they have received the following training specific to enable them to meet the needs of service users living in the home, epilepsy, autism, mental health needs, behaviour awareness, philosophy of care and Person Centred Planning (PCP). 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 21 It was recommended that the manager devise a training matrix to enable easier monitoring of staff training needs and achievements. Records seen indicated all staff are employed in accordance with a corporate recruitment and selection procedure designed to protect service users. This involves the completion of an application form, the signing of a rehabilitation of offenders declaration, 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 manager confirmed and records seen indicated all new staff are involved in an initial corporate in house five-day induction programme followed by The Learning Disability Awareness Framework (L.D.A.F.) accredited training (induction and foundation) prior to being involved in a NVQ training programme. Staff said they receive support from one another, one staff said ‘we are friends and work well together. Records were seen to show that all staff received formal, structured supervision on a regular basis by the manager, who has received appropriate training. One member of staff said ‘ I have regular supervisions and I get a copy of the records detailing what was discussed.’ On the day of the inspection there were sufficient number of staff on duty to meet individual and group needs. The manager said that either herself or a senior support worker is on shift at all times, the rota confirmed this. One member of staff said there is an efficient ‘on call’ system in place if needed. Staff provide wake and sleep in cover during each night shift. The staff undertake the cooking and cleaning with the service users assisting where possible. 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 22 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. This judgement has been made using available evidence including a visit to this service. Service users’ are benefiting from living in a home which is being run well. Service users views are sought frequently. Service users are protected by staff being well trained and showing a sound knowledge within the areas of health and safety. EVIDENCE: The home’s manager has been registered with the CSCI for three years and is completing her Registered Managers Award (RMA) and NVQ level 4 in care. 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 23 The home arrange monthly staff meetings, minutes of the most recent meeting were seen, one staff member said the majority of staff attend. Records were seen of service users views of the home being sort on a regular basis, by service users meetings, on a one to one basis with their link worker, formally once a year in the form of a pictorial questionnaire, and by annual reviews with social workers/care managers. The responsible individual completes monthly unannounced audits to comply with regulation 26 of the care homes regulations 2001, a copy of these reports were available in the home, and would be sent to the Commission on request. The staff are continuing to improve ways in which they can ensure service users views are obtained, they have introduced a wide range of pictures to encourage service users to communicate, they say they work very well with service users, this was apparent during the inspection by the interaction, service users appeared relaxed and seemed to enjoy staffs’ company. The staff complete regular weekly health and safety checks to ensure the safety of the building. Certificates were seen to show regular servicing of the boiler, electrical items, fire safety equipment and liability insurance. All Control Of Substances Hazardous to Health (COSHH) sheet corresponded with the cleaning chemicals used in the home. All of the hot water supplies to baths were fitted with thermostatic controls set at 43 degrees centigrade and all radiators and hot pipes were covered. There were various health and safety procedures in place within the kitchen including colour co-ordinated chopping boards, a cleaning rota, gloves, temperature recording including probing of food, fridges and freezers. Records of staff attending fire training and practices were complete, and staff confirmed they had been on duty when the fire alarm had been activated and were confident of the home’s evacuation procedure. 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 24 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 4 3 X 4 X 5 3 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 X 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 x 3 X 3 X X 3 x 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 25 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. 1 2 Refer to Standard YA22 YA35 Good Practice Recommendations Service users may benefit from the homes policies and procedures being available in picture format, especially the complaints procedure. The manager to devise a training matrix to enable easier monitoring of staff training needs and achievements. 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 40 Cody Road DS0000011560.V320364.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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