Inspection on 10/09/07 for 44 Blyford Road

This inspection was carried out on 10th September 2007.

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

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

Other inspections for this house

44 Blyford Road 20/09/06

44 Blyford Road 25/01/06

44 Blyford Road 24/08/05

44 Blyford Road 21/02/05

44 Blyford Road 04/08/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 44 Blyford Road 44 Blyford Road Lowestoft Suffolk NR32 4ST Lead Inspector John Goodship Key Unannounced Inspection 10 September 2007 13:50p th 44 Blyford Road DS0000024338.V349447.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 44 Blyford Road DS0000024338.V349447.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. 44 Blyford Road DS0000024338.V349447.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 44 Blyford Road Address 44 Blyford Road Lowestoft Suffolk NR32 4ST 01502 531007 F/P 01502 531007 h2031@mencap.org.uk www.mencap.org.uk Royal Mencap Society 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) Mrs Karen Smith Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (2), Physical disability (2) of places 44 Blyford Road DS0000024338.V349447.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2006 Brief Description of the Service: The bungalow is situated in north Lowestoft in a pleasant residential area. There are some shops close by. It was purpose built for 6 people with learning disabilities. The home was extended and refurbished in 2003 to offer more spacious accommodation for two individuals with physical disabilities, widening all the doors in the existing building, and lowering all light switches and plug sockets to wheelchair height. A third person with physical disabilities was admitted in March 2004. The building is owned by Orbit Housing Association. The service is provided by Mencap. The fees currently charged range from £454.77 to £1183.77 per annum. 44 Blyford Road DS0000024338.V349447.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a weekday and lasted four and a half hours. The manager was present throughout, together with staff on the morning shift and, later, those on the late shift. The inspector toured the home, spoke to two support workers, and also to those residents who were able to communicate. The inspector also examined care plans, staff records, maintenance records and training records. A questionnaire survey was sent out by the Commission to residents and to relatives. None of the residents were able to reply. One relative did so, and two staff members. Their answers to the questions and any additional comments have been included in the appropriate sections of this report. The home was also required to complete an Annual Quality Assurance Assessment, which helped to inform the inspection. Some of the information provided has been used in this report. What the service does well: The home has a comprehensive pre-admission assessment process which identifies the needs of a prospective resident and forms the basis for their care plan. The home is purpose built with a recent upgrading providing improved space and specialist equipment for the most disabled residents, and proper provision for all disabled residents. Staff and residents communicate well, and there is good understanding of residents’ needs and wishes. Care plans and other written material try to express these in the first person which emphasises the person-centred attitude of the home. Residents are supported to achieve their potential, and follow their interests. In-service staff training is comprehensive and well documented. The home encourages continuing contact with families. Previous comments from relatives confirmed this, and this time a relative wrote that there was always information readily available about the care given. The home demonstrates good practice by including medication profiles in each person’s drug record sheet which explains the reasons for the drug’s prescription and any side-effect it may have. 44 Blyford Road DS0000024338.V349447.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 44 Blyford Road DS0000024338.V349447.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 44 Blyford Road DS0000024338.V349447.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): 2,4,5. Quality in this outcome area is good. Prospective residents can expect that the home will assess their needs and the suitability of the home for them, and that they will have an introductory period to test that they will like living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A resident had been admitted to the home in March 2006. In their file was the pre-admission assessment, developed from a visit by the manager to their previous home, and also drawing on information from the Compass report from Social Care Services, a physiotherapy assessment and a visit to Blyford Road by the prospective resident. However this person had been diagnosed in January 2007 with dementia. Initially the home had been able to care for them as their primary condition of a learning disability was their principal care need. Nevertheless, the home should have applied for a variation to their registration to cover this additional diagnosis. The individual placement contract for this resident was in their file. It had been signed in April 2006. Each resident also had a copy of the Mencap terms and conditions of residence. There was evidence that new residents lived in the 44 Blyford Road DS0000024338.V349447.R01.S.doc Version 5.2 Page 9 home for a trial period at the end of which a review was held with all parties including the funder. 44 Blyford Road DS0000024338.V349447.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 excellent. Residents can expect the home, and their daily lives, to be run according to their needs and wishes, with the development of independence through planned risk-taking as a primary goal. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The resident who had the diagnosis of dementia was case-tracked, with detailed study of the care plan, reading of review notes, and observation. The care plan charted the significant change in care needs and behaviour in the last three months. Risk assessments and staff guidance had been updated as the needs changed. For example, there were detailed descriptions of how behaviour was affected by the number of care staff giving personal care, and it listed when one, two or three staff were required to support the resident. Behaviour charts were kept, with two recordings each day showing the 44 Blyford Road DS0000024338.V349447.R01.S.doc Version 5.2 Page 11 increased staff commitment to this resident. particular notes were made giving staff guidance on how to reduce the resident’s anxiety. In some cases, changes were necessary on a daily basis. There was a detailed support plan for food and feeding, with input from the speech therapist. A multi-disciplinary review in August 2007, a record of which was on file, agreed that this resident’s needs met the critical risk band definition. It was suggested that their needs could only be fully met in a care home with nursing people with dementia. The manager and the provider were concerned that the needs of this resident were drawing staff away from giving other residents the support they needed. Eighteen additional staffing hours had been funded while the resident was receiving day care with the local authority, but no additional hours had been funded since the day care could only be given in the home. The provider had written to Social Care Services in September 2007 giving formal notice that the home could no longer provide for this resident’s needs. The Commission had been informed of this. An alternative home was being sought. There were risk assessments for other residents for activities inside and outside the home. They covered areas such as bathing and showering, transferring from wheelchair to armchair and to bed, travelling in the minibus, travelling on an aeroplane, using the kettle to make a hot drink, and risks associated with a resident who suffered from severe epilepsy, who needed staff to administer rectal diazepam on occasions. In all cases there was guidance for staff on supporting residents so that the risks were minimised without reducing the residents’ choice of activity. The manager stressed that the ethos of the home was to enable residents to do things they wanted to do safely, not to prevent them doing them. The assessments appeared to reflect residents’ wishes and covered a wide range of activities according to each resident’s abilities and wishes. Staff signed to confirm that they had read the assessments. All residents had been reviewed by Social Care Services last year to assess whether each resident was correctly placed at Blyford Road, or if their needs could be met more appropriately in an alternative residential setting or in supported living accommodation. All the reviews were held with the resident apart from two who chose not to attend. Relatives were invited to the reviews. All the reviews commented that the home was very well managed, and that the paperwork required for the review was kept in good order. One person had been considered for supported living and is on the housing list, but after a deterioration in their health, it was felt that the home currently provided the appropriate support and care. However, if a property became available, they could be re-assessed. 44 Blyford Road DS0000024338.V349447.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): 11,12,13,14,15,16,17. Quality in this outcome area is excellent. Residents are given many opportunities to choose how to spend their time, as a group, and individually. Residents are encouraged to play an active part in the running of the home according to their wishes and abilities. They will be supported to maintain contact with their relatives as they wish. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents had a planned programme of day care during the week, either at home or at an external day service. Five residents attended local authority centres, although there was some doubt about how long one resident, who was over sixty-five, would be allowed to continue. They had been changed to another centre on Fridays, but had refused to go because they would not be doing woodwork. One resident attended another local authority centre on five days although for one of those days they were taken to spend the day with 44 Blyford Road DS0000024338.V349447.R01.S.doc Version 5.2 Page 13 their relative. They had been taken by staff of the day centre, but staff of the home were now using the home’s transport to do this. One resident went to a social club in a nearby town once a week in the evening. Residents took part in a variety of leisure activities - inside the home, such as listening to their own tapes, watching television as a group or in their own room, helping with cooking and gardening; outside the home, such as going to shows, shopping and bowling. Some also participate in activities organised by SCOPE, Club 85 and the local Gateway Club. One resident was described as needing encouragement to go out, but then enjoyed doing so. The AQAA reported that staff tried to find out what leisure activities residents would like to take part in including holidays. Five of them had been or were going on holiday. Two had gone to a holiday centre in Berkshire supported by three staff, two residents and two staff had been on a coach holiday to Shropshire, and one had already been on holiday with their parents. One resident had planned a coach touring holiday to go away but this was cancelled because they were booked for a knee replacement operation which would not have allowed enough time to recuperate before the holiday date. One resident had been to London recently with their dance group and said how much they enjoyed it. One resident was taken regularly to see their sick relative who was in a nursing home. These visits were recorded in the daily records. These daily records contained full information for each resident on their activities, outings, health matters, and other aspects of each day. The kitchen was clean and a good size. The manager said that they had been promised an upgrade by the landlords (a housing association) but no date had been set. There was a list in the kitchen giving staff information about the preferences of residents. Under each resident it listed requests in the first person such as: “Please don’t give me………” and “ I prefer breast meat to leg meat”. One resident, who was at home due to health problems was helping to grate the cheese for the cheese pie which was for the evening meal. They had been out with staff and another resident to buy the cheese. The menu was varied and nutritious, and there plenty of fruit in baskets for residents to help themselves. The evening meal was taken in the dining room. Some residents were supported to eat by staff. The atmosphere was calm and cheerful. 44 Blyford Road DS0000024338.V349447.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 excellent. Residents can expect their needs to be identified, monitored and appropriate action taken. They are protected by the home’s training and administration policies for dealing with medicines. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each care plan contained an individual Support Plan written in the first person, to reflect the point of view of the resident. Examples were: “If I fall down and am unable to get up………”, “If I cut myself or hurt myself when I have a shower……….”, followed by clear instructions for support workers on how to support without reducing dignity or preventing independence. The resident with dementia had very detailed support plans for their personal care. Health concerns were reported promptly to the health professionals. One resident had an ulcerated leg which was proving slow to heal. The district nurse was treating it regularly. The same person was also booked in for a knee 44 Blyford Road DS0000024338.V349447.R01.S.doc Version 5.2 Page 15 replacement. The manager stated that the family had been informed about this. Another resident was on the breast-screening programme. One resident had had dental work done in the local hospital. Occupational therapy, the community nurse and the psychologist had been involved with one resident. A care plan showed that staff had noticed that one resident had a sore patch around the groin. There was a body map in the daily record with an instruction for staff to treat and monitor. The medication records were examined. It was good practice that there were medication profiles in the front of each MAR sheet giving explanatory information on each prescribed drug. Tablets were administered from blister packs which were stored by name and time of day. The rear of each sheet was used to record when medicines marked as PRN were administered and why. It was noted that bottles were dated when opened. There were no gaps in signing for medication administered on the record sheets. Staff who administered medication had been trained on the Mencap “Working safely with medicines” distance learning course. Evidence was seen in the training record. Staff had also been trained to administer rectal diazepam, however the one resident who had been prescribed this had been reviewed by their GP and taken off this medication as they had had not had a seizure for three years. 44 Blyford Road DS0000024338.V349447.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. Residents are helped to understand how they are protected, and how to raise issues of concern. Their finances are protected from abuse by proper procedures, and discrepancies are investigated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home followed the Mencap Complaints policy and procedure which complied with the Standard. A poster was displayed in the kitchen explaining the policy to residents in cartoon format and clear lettering. The area manager had written to the Social Care Services in July 2007 stating that the placement of one resident was now inappropriate and put other residents staff in danger. He asked for this to be treated under the Protection of Vulnerable Adults policy and procedure. No information about this was sent to the Commission although details of incidents were sent under Regulation 37. In fact a strategy meeting to review this placement had been arranged by the time the letter was sent. No formal complaints had been made to the home or to the Commission in the previous twelve months. 44 Blyford Road DS0000024338.V349447.R01.S.doc Version 5.2 Page 17 The inspector checked the personal cash records of one resident. This person was chosen because the manager had explained that, when auditing the records, it was found that their cash was short by £21. The books showed proper receipts and records with regular checking by the manager. Allowances were recorded as paid into the bank, and bank statements were correct. The inspector noted that the reason for the discrepancy was not clear. The provider was investigating and later informed the Commission that nearly all the money had been accounted for. The small difference was reimbursed to the resident. A new procedure had been put in place to tighten up the checks and recording of transactions. The original discrepancy was not reported to the Commission under Regulation 37. 44 Blyford Road DS0000024338.V349447.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): 24,27,29,30. Quality in this outcome area is adequate. Residents continue to live in a purpose-built home with some appropriate facilities and specialist equipment and furniture for their needs. However their safety cannot be assured until bathroom facilities have been improved, and the external area made wheelchair accessible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was upgraded three years ago to include facilities to meet the needs of three residents with physical disabilities. The manager stated that if a new resident with physical disabilities moved into the home, it might be difficult to accommodate their needs due to the position of the high/low baths and which bedrooms became vacant. 44 Blyford Road DS0000024338.V349447.R01.S.doc Version 5.2 Page 19 A tour of the building showed that there had been no change to the individual and communal facilities since the last inspection when all these standards were examined and were met. The kitchen floor had been replaced last year. New kitchen units were planned but there was no date yet from the landlords, Orbit Housing Association, for them to be fitted. The home had been waiting for over a year. The kitchen was clean and tidy. Items in the fridge were covered and dated. Temperatures were recorded regularly. The bathroom with a ceiling hoist had had a Malibu bath installed to make it easier and safer for residents to bath. However the work had not been completed properly, as the doorway needed alteration, tiling was not finished and the WC had been moved but not the grab rails. There was also little room to access the built in bathing chair unless the wall was removed. The manager reported that there was disagreement between the landlord, the provider and the bath installers about responsibly. This must be resolved for the safety of residents and staff. The secure garden was not well maintained and looked unattractive. It was not easily accessible by those in wheelchairs. 44 Blyford Road DS0000024338.V349447.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): 32,33,34,35,36. Quality in this outcome area is good. Staff were observed to interact well with the residents. They were able to communicate with them all. This was evident either by verbal responses or by non-verbal signs such as smiling and nodding. Staff were knowledgeable about the needs of residents and their likes and dislikes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels were determined by the daytime programmes of the residents. There were four staff programmed on each morning to cover getting up and having breakfast, and four in the afternoon and evening. This level was needed to support a resident with complex needs who sometimes required three staff for elements of personal care. At weekends, the home was fully staffed all day. There were two part-time vacancies, one on nights and one on days. These were being covered partly by the use of agency staff. 44 Blyford Road DS0000024338.V349447.R01.S.doc Version 5.2 Page 21 Staff training was organised through the provider’s training programme. Training records were kept in each person’s personal file. Staff were up-to-date on the routine programmes such as moving and handling, fire procedures, food hygiene and medication. Staff confirmed that they had received training in adult protection. 50 of the staff had achieved NVQ Level 2 or above. The schedule for staff supervision sessions was displayed on the office wall. However the manager explained that these were not up-to-date because of the pressure of supporting the resident with the highest needs. In addition all staff underwent an annual appraisal. This schedule too was displayed on the office wall. The files of two staff members were examined. They contained all the records, ID documents and recruitment checks required. The files also contained training certificates, and induction programmes. Staff were observed to interact well with the residents. They were able to communicate with them all. This was evident either by verbal responses or by non-verbal signs such as smiling and nodding. Staff were knowledgeable about the needs of residents and their likes and dislikes. 44 Blyford Road DS0000024338.V349447.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): 37,39,40,41,42. Quality in this outcome area is good. Residents can expect that the home will be run in their best interests, with their views sought regularly by internal and external visitors. Their health, safety and welfare is promoted but cannot be fully protected until the fire safety requirements have been actioned. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager was registered with the Commission and was experienced in the care of this client group. She had completed her NVQ Level 4 and had got the Registered Manager Award. Staff commented on the support they received from the manager. 44 Blyford Road DS0000024338.V349447.R01.S.doc Version 5.2 Page 23 The home used the services of a lay visitor who visited the home quarterly. A report was written of the visit and these were kept in the hall. Comments were positive and encouraging. A survey had recently been sent out to relatives, the day centres and GPs. Replies went back to the Area office. The manager had not yet seen the results. The results of previous surveys had given positive comments particularly from relatives. Regular monthly visits were paid by the area officer who completed a report, which also met the requirements of Regulation 26. These were available in the home. The manager usually held staff meetings at six weekly intervals, and residents meetings when there was a topic to talk about. This was usually the Christmas arrangements, or decisions on where residents wanted to go on holiday. The fire log showed that there were regular maintenance checks on fire equipment. The fire alarm was tested weekly with a practice evacuation twice a year. There was also a fire risk assessment which was due to be reviewed. The manager reported that Mencap used an external firm to update these assessments. The local fire officer had inspected the home in March 2007 and made two requirements, one for an additional smoke detector in a cupboard, and for self-closers on doors. Neither of these had been actioned. The home abided by Mencap policies and procedures. Nationally Mencap had a process to involve users in the review and development of policies although none of the residents of Blyford Road were involved in this. 44 Blyford Road DS0000024338.V349447.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 3 3 X 4 3 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 2 25 3 26 3 27 2 28 3 29 4 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 4 12 3 13 3 14 4 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 3 3 3 2 X 44 Blyford Road DS0000024338.V349447.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. 1. Standard YA23 Regulation 37 Requirement The Commission for Social Care Inspection must be notified of all significant incidents affecting the home or a resident. The fire officer’s requirements must be implemented as soon as possible, and the Commission notified. Timescale for action 10/09/07 2. YA42 23(4) 31/10/07 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 YA24 YA27 Good Practice Recommendations All parts of the home should be accessible to residents including those in wheelchairs. The assisted bathroom should be completed as soon as possible. The Commission for Social Care Inspection should be informed of the completion date. 44 Blyford Road DS0000024338.V349447.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office Fairfax House Causton Road Colchester ESSEX CO1 1RJ 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 44 Blyford Road DS0000024338.V349447.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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