Inspection on 24/04/07 for 40 Kingsland Avenue

This inspection was carried out on 24th April 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 Kingsland Avenue 02/11/05

40 Kingsland Avenue 04/10/04

40 Kingsland Avenue 17/05/04

40 Kingsland Avenue 12/03/04

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

CARE HOME ADULTS 18-65 40 Kingsland Avenue Northampton Northants NN2 7PP Lead Inspector Linda Clarke Key Unannounced Inspection 24th April 2007 09:30 40 Kingsland Avenue DS0000012832.V334337.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 Kingsland Avenue DS0000012832.V334337.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 Kingsland Avenue DS0000012832.V334337.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 40 Kingsland Avenue Address Northampton Northants NN2 7PP 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) 01604 791839 Royal Mencap Society Mrs Angela Ruth Wilding Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places 40 Kingsland Avenue DS0000012832.V334337.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The total number of service users residing at the home must not exceed 3 Up to three service users may be in the category of Learning Disability. (LD) Once three service users in the category of LD are residing at the home, no more may be admitted Up to three service users may be in the category of Mental Disorder, excluding learning disability or dementia (MD) Once three service users in the category of MD are residing at the home, no more may be admitted 2nd November 2005 Date of last inspection Brief Description of the Service: 40 Kingsland Avenue is a care home providing personal care and accommodation for up to 3 persons with a Learning Disability and potentially an associated Mental Disorder. The three single bedrooms are without en-suite facilities, one bedroom being located on the ground floor, with the remaining two bedrooms being located on the first floor. In addition the ground floor provides a lounge, kitchen diner, utility room and walk-in shower, whilst the first floor provides a bathroom and office. The first floor being accessible via a stairwell. The front door has level access provided by a ramp, whilst the rear garden has a patio area, and has mature plants and shrubs. Information is located on site detailing the range of services offered, which includes the Statement of Purpose and a copy of the Commission for Social Care Inspections Inspection Reports, which are located in the office. Fees payable are dependent upon an assessment undertaken by Care Management, which will determine the level of contribution payable by the service user. There are additional costs payable for activities and purchasing of personal items. 40 Kingsland Avenue DS0000012832.V334337.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process consisted of pre-planning the inspection, reviewing the last inspection report and the reviewing of the Pre-Inspection Questionnaire and Comment Cards/Surveys distributed to service users and their relatives by the Commission for Social Care Inspection (CSCI) along with the reviewing of significant events. The unannounced site visit commenced on the 24th April 2007 and took place over 1 day. The focus of the inspection is based upon the outcomes for the service users. The method of inspection was ‘case tracking’. This involved identifying service users with varying levels of care needs and looking at how these are being met by the staff at the agency. Two service users were selected of which, three service users were spoken with, supported by care staff and were observed returning from their daytime occupation. The method of case tracking included the review of service users’ individual care records, discussions with staff individually and collectively with various delegated responsibilities within the service and reviewing the staff training records and observing the management of the service. The inspection also involved looking at the office layout and the storage of information; where the day-to-day operations take place, reviewing of the records including revised policies and procedures, complaints, compliments and any safe guarding adult issues. The CSCI sent out Comment Cards to service users, of which all were returned, in addition one comment card was received from a service users relative. Comments incorporated within Service User Comment Cards included: No additional comments were incorporated within Service User Comment Cards, staff confirmed that they completed the Comment Card on behalf of the service user, with service user involvement. Responses to questions indicated that service users were happy with the care they received, that they are supported to make decisions and have an active part within the community engaging in recreational and leisure activities. Service users felt that they were treated well, and were confident in knowing how to raise concerns. Comments incorporated within Relative Comment Card included: • I can’t fault the house, of the care staff. 40 Kingsland Avenue DS0000012832.V334337.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Information about Kingsland Avenue could be made easier for people to understand by included photographs, and by the use of more symbols and signs. Service users currently take part in an annual survey distributed by Mencap, which asks them to comment on the care and service they receive, currently there isn’t a formal process, which tells service users the outcome, and any possible changes. Mencap should consider producing information to service users in an appropriate format so that those that take part know that their views have been considered. The quality assurance process could be increased to include the views of service user relatives/friends and those who support service users such as health and social care professionals, with a report being produced as the results of the survey, which includes a plan any changes to improve its service. 40 Kingsland Avenue DS0000012832.V334337.R01.S.doc Version 5.2 Page 7 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 Kingsland Avenue DS0000012832.V334337.R01.S.doc Version 5.2 Page 8 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 Kingsland Avenue DS0000012832.V334337.R01.S.doc Version 5.2 Page 9 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): 1, 2 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with information detailing the services offered by Kingsland Avenue, and current service users benefited from a detailed assessment of need prior to their moving into the home. EVIDENCE: Service users benefit from having a Statement of Purpose which outlines the role of the care home, providing additional information as to the services offered, the accommodation and information on policies and procedures. The Statement of Purpose has not been reviewed for a while, however the Registered Manager confirmed that its her intention for it to be reviewed, this was highlighted by Mencaps’ own Quality Assurance processes. Service Users also benefit from a Service User Guide, providing written information about the service, written information being supported by symbols and pictures, however further improvements could be made to the document by the inclusions of photographs. 40 Kingsland Avenue DS0000012832.V334337.R01.S.doc Version 5.2 Page 10 Service users currently living at Kingsland Avenue have done so for a number of years, all being assessed by a representative of Social Services, the Registered Manager confirmed that if a vacancy was to become available then a representative of Social Services would undertake an assessment of the individuals care needs. Service user have a contract which details the terms and conditions of their residency, including their financial contribution for their care. 40 Kingsland Avenue DS0000012832.V334337.R01.S.doc Version 5.2 Page 11 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, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users independence is promoted, whilst being supported to make individual decisions in all aspects of their lives that have a direct impact on the quality of care they receive, and their lifestyle. EVIDENCE: Service users residing at the home have recently had their needs re-assessed to ensure that the care they are receiving is appropriate to their lifestyle and needs, the re-assessment process has resulted in a representative of Social Services updating service user care plans. Service users benefit from a Person Centred Plan which provides details as to the individuals personal goals, detailing their strengths, where support is required information states as to how the service user wishes to be supported. The Person Centred Plans reflect service user wishes and preferences, and detail their preferred daily living routines, such as time of getting up, whether 40 Kingsland Avenue DS0000012832.V334337.R01.S.doc Version 5.2 Page 12 they wish to eat breakfast before or after having a shower, their evening occupation and activities including information as to how these choices are to be supported. This process ensures that the care service users receive is reflective of their decisions and choices. The Person Centred Plans are the property of service users who keep them within their bedroom, and are signed by the service user and a member of care staff. Daily records of the two service users case tracked were viewed, information recorded evidenced that service users Person Centred Plans were adhered to, with information being recorded as to their decisions, and leisure pursuits. Person Centred Plans document the financial support service users require, with any financial transactions being recorded. Service users have a safe which is kept in their bedrooms, all service users have an account with a local Bank or Building Society, and the Person Centred Plan describes the level of support the individual service user requires with regards to managing their finances. All service users pay an individual amount towards their residence and care, using the local Post Office to make a payment. Service users have a weekly meeting, whereby issues affecting themselves individually or collectively are discussed. An issue discussed each week is the meal choices for the following week, with a rota being in place for a service user to undertake a weekly shop at the local supermarket supported by a member of care staff. Person Centred Plans and Care Plans are supported by risk assessments, which support service users to take risks as part of their lifestyle choices, areas which were risk assessed including, a service user smoking, accessing public transport independently, road awareness, making hot drinks and undertaking household tasks to name some. Staff demonstrated through their conversation and interaction with service users, a clear understanding of their role in offering support and guidance, and awareness as to the rights of service users to express opinions and make decisions, observations of interactions between service users and staff highlighted a level of trust and understanding which ensures service users are relaxed within their home. 40 Kingsland Avenue DS0000012832.V334337.R01.S.doc Version 5.2 Page 13 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, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy, experience and participate in different activities of interests and are supported to maintain their preferred individual daily routines and choice of lifestyle with the support of the staff, if required. EVIDENCE: Service users residing at Kingsland Avenue attend a variety of day care facilities on weekdays, with one service user spending one day of the week at home. Person Centred Plans and risk assessment detail as to how service users travel to their daytime occupations in a safe manner. Kingsland Avenue is centrally located and has a number of services within walking distance; these include two large supermarkets, a variety of independent shops and banks, cafeterias, and places of Worship. 40 Kingsland Avenue DS0000012832.V334337.R01.S.doc Version 5.2 Page 14 Documentation confirmed that Service Users are registered on the electoral role, with polling cards being in place for the forthcoming local elections. Person Centred Plans detailed the level of support service users require with regards to mail they receive. Service users benefit from accessing and taking part in a variety of recreational and leisure activities, these include bingo sessions held at the local Church, one service user being a member of a Bowling Club, one service user being a member of a Sailing Club, cinema, quiz nights, meals out, shopping and visits to local parks and places of interest. One service user was looking forward to her theatre trip to London to the Sound of Music production; the service user said she had been to a number of theatre productions. Service users had recently attended a talk by the Mayor on Hedgehogs, which all service users reportedly enjoyed. One service user had organised their holiday to Great Yarmouth with a friend and two members of care staff, whilst the other service users were hoping to organise a holiday through an organisation, who specialise in offering holidays and breaks to individuals with a disability. Last summer holiday destinations included Skegness and Euro Disney in Paris, France. Relatives and friends of service users are encouraged to visit, and staff offer support to maintain family links. One service user receives regular telephone calls from a relative who lives overseas; service users answer the homes phone. Service users bedrooms are locked, with service users having a key to their room. The Statement of Purpose details that service users can keep pets with the agreement of all those residing at the home, at the time of the site visit a Cat by the name of ‘Snowy’ lived at the home. Specialist diets are currently not required by service users residing at the home, service users have adopted a healthy diet, and discuss the meals for the week at the weekly meeting. Service users supported by a member of staff undertake the weekly shop at one of the two local Supermarkets. A member of staff supported a service user to make dessert for the evening meal, whilst other service users were encouraged to set the table for the evening meal. The member of staff offered encouragement and support, enabling service users to maximise their skills, and contribute to the running of their home. 40 Kingsland Avenue DS0000012832.V334337.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user health care needs and independence is promoted by receiving timely care and support provided in the preferred way. EVIDENCE: The personal support individual service users require is detailed within their Person Centred Plans, with emphasis being on service user abilities and strengths. Information recorded includes hairstyle choices, clothing preferences, and preferred daily routines including times of getting up. Service users currently do not require any specialist equipment; the home does provide a walk-in shower on the ground floor. Service users have a named ‘keyworker’ who is responsible for the organisation of trips including holidays and overseeing their care plan promoting consistency of care. Service users have a health care plan, which is presented in large print supported by signs and symbols enabling service users to understand the document and its contents. Records confirmed that service users benefit from a range of health care services, which include dentists, general practitioners, 40 Kingsland Avenue DS0000012832.V334337.R01.S.doc Version 5.2 Page 16 nurses, learning disability nursing services, chiropodists and opticians. Documentation details the level of support service users require in accessing health care including the issues relating to medication. The medication records and storage of medication for one service user was viewed and found to be in good order. All staff responsible for the administration of medication undertakes training. A member of staff supported a service user in accessing health care following a recent fall, which left the service user with a swollen hand. 40 Kingsland Avenue DS0000012832.V334337.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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by a robust and accessible complaints procedure and by staff trained in safe guarding adult processes. EVIDENCE: Kingsland Avenue uses a form to record, complaints and concerns. Documentation submitted by the Registered Manager prior to the site visit detailed that their have been no complaints with regards to the service, the Commission for Social Care Inspection has equally not received any concerns or complaints since the last Inspection. Service users within their Person Centred Plans have a copy of the Complaints Procedure, which is produced in large print supported by pictures and symbols for ease of reference by service users. Staff have received training in safeguarding adult protocols, enabling staff to recognise and respond to allegations or suspicion of abuse, policies and procedures developed by the Local Authority and Mencap offer guidance and support to service users and staff. 40 Kingsland Avenue DS0000012832.V334337.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, 26 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with a warm, safe, clean, comfortable and wellmaintained environment suitable for their needs. EVIDENCE: Kingsland Avenue is a town house, set within a residential area and benefits from local services and amenities; access to the ground floor via the front is via a level access ramp, which leads into the hallway. The ground floor has a lounge, kitchen/dining area, utility room and walk-in shower room, along with a bedroom. Access to the rear garden is from the utility room, and provides amply space for service users to relax outside. The first floor of the property is access via a stairwell, with two additional bedrooms, bathroom and office. Bedrooms do not benefit from en-suite facilities. 40 Kingsland Avenue DS0000012832.V334337.R01.S.doc Version 5.2 Page 19 Furniture and fittings are in good decorative order, with bedrooms being personalised to reflect individual service user choices. Service users Person Centred Plans details as to the laundering of their clothing, and the level of support required, the home provides a variety of domestic appliances which include a dishwasher, washing machine and tumble dryer, service users are supported to use all of the domestic appliances. 40 Kingsland Avenue DS0000012832.V334337.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, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of trained staff are recruited through a robust recruitment process ensuring that service user care and social needs are individually, collectively and safely met. EVIDENCE: Five members of care staff along with the Registered Manager support the service users, two members of care staff having attained a National Vocational Qualification one being at level 2 and one being at level 3. Staff have undertaken training in professionalism, supporting staff to interact appropriately with a variety of health and social care professionals ensuring service users are supported appropriately. The staffing rota details that one member of staff is on duty during the day, with one member of staff sleeping on the premises overnight. The staffing levels are very flexible, and provide additional staff to facilitate service users engaging in recreational and leisure pursuits. Staffing at the home has been consistent, with a number of staff having worked there for a while, whilst even 40 Kingsland Avenue DS0000012832.V334337.R01.S.doc Version 5.2 Page 21 the most recent members of staff having transferred from other Mencap homes. Staff attend regular team meetings, minutes of the meetings were viewed and evidenced that staff have the opportunity to discuss issues relating to service users, themselves such as training, and plan for events affecting service users. In addition staff have the opportunity to participate in a staff forum, which is held across the Mencap Eastern Region. On the day of the site visit a team meeting was held. The records of two members of staff were viewed who were ‘keyworker’ to the service users ‘case tracked’, both contained relevant pre-employment checks such as a Criminal Record Bureau check and were supported by an application form and two written references. Staff files and discussions with staff highlighted the training which staff have access to, which includes health and safety, first aid, food hygiene, report writing, equality and diversity, safeguarding from abuse, supporting behaviour, medication and Person Centred Planning to name some, the training enables staff to offer the appropriate support and care for service users, ensuring service users lead an active and fulfilling life in line with their wishes and expectations. The Registered Manager acknowledged that staff have regular supervisions which are recorded, these however were not in all instances as frequent as she would like, or in line with Mencap policy. The Registered Manager spends a majority of her time working Monday to Friday, which ensures she meets with all staff regularly, however does work weekends and evenings when required. 40 Kingsland Avenue DS0000012832.V334337.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 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager offers a clear sense of leadership, ensuring service user health; safety and welfare are promoted. Service users are provided with opportunities to comment on and affect the service they receive. EVIDENCE: The Registered Manager, Angela Wilding has worked for Mencap for several years, and has been the Registered Manager for Kingsland Avenue since January 2006. Angela Wilding has attained the Registered Managers Award and the National Vocational Qualification in Care award at level 4, in addition attending a variety of courses relevant to her role and responsibilities. 40 Kingsland Avenue DS0000012832.V334337.R01.S.doc Version 5.2 Page 23 Mencap operates an annual quality assurance process, which includes sending out questionnaires and surveys to all its service users, the documentation is produced in large print supported by pictures and symbols for the benefit of its audience. The Registered Manager advised that the results of these surveys are collated, and any action required is taken. The Registered Manager however stated that the results of the survey are not published for the benefit of service users, but are discussed with them as appropriate. It is recommended that service users should have the option of viewing the outcome of the quality assurance process including a plan of any action Mencap intend to take; this should be produced in a format appropriate to the needs of service users. It is further recommended that the quality assurance process includes seeking the views of service user relatives/friends and those providing support such as health and social care professionals, and the results are included within the final document produced, and made available to all participants. As part of the quality assurance process, the Registered Manager on a monthly basis is visited by her line manager, who reviews a variety of documentation, speaking with service users and staff, following the visit a report if produced of their findings detailing any actions which the Registered Manager or Mencap as an organisation has to address, the Registered Manager on a monthly basis undertakes an audit of health and safety issues. In addition service users participate in weekly meetings and forums with other Mencap residential care homes in the area. The meeting and forums provide service users with an opportunity to meet and discuss issues, which affect them, and provides an opportunity to mix with other individuals in a similar situation. The Pre Inspection Questionnaire submitted prior to the CSCI prior to the site visit detailed the regular maintenance of health and safety systems within the home, including fire systems and equipment, environmental health visits, central heating systems and emergency call systems. Records detailing fire drills and checks were viewed, and found tests to be carried out on a regular basis; additionally service user daily notes reflected their involvement in fire drills. 40 Kingsland Avenue DS0000012832.V334337.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 2 2 3 3 3 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 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X 40 Kingsland Avenue DS0000012832.V334337.R01.S.doc Version 5.2 Page 25 Not Applicable 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. Refer to Standard YA1 Good Practice Recommendations Prospective and current service users may benefit from documentation about Kingsland Avenue including photographs and additional signs and symbols for ease of reference. It is recommended that the results of the quality assurance system along with any action to be taken by Mencap as a result of the survey is produced and distributed to service users and is published in an appropriate manner format reflective of service users needs. It is recommended that the quality assurance process be increased to include seeking the views of service user relatives and friends and those involved in their care such as health and social care professionals, with a report of the findings being made available to the participants. 2 YA39 3 YA39 40 Kingsland Avenue DS0000012832.V334337.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Kingsland Avenue DS0000012832.V334337.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. 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!