Inspection on 14/08/07 for 45 Mayfield Park North

This inspection was carried out on 14th August 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

45 Mayfield Park North 20/09/06

45 Mayfield Park North 28/02/06

45 Mayfield Park North 09/08/05

45 Mayfield Park North 04/02/05

45 Mayfield Park North 25/05/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 45 Mayfield Park North Fishponds Bristol BS16 3NH Lead Inspector Sandra Jones Key Unannounced Inspection 14 & 22nd August 2007 09:30 th 45 Mayfield Park North DS0000026563.V340414.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 45 Mayfield Park North DS0000026563.V340414.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. 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 45 Mayfield Park North Address Fishponds Bristol BS16 3NH 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) 0117 9583869 0117 9709301 admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mr Ioan Williams Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (5) 45 Mayfield Park North DS0000026563.V340414.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: Mayfield Park North is a care home for five adults with mental health care needs. It is operated by Aspects and Milestone Trust and managed by Ioan Williams. The property has the appearance of a domestic dwelling, which blends well with its immediate environment. It is close to shops, amenities and bus routes. Arranged over three floors, with shared space on the ground floor and bedrooms on the lower ground floor and first floor. There is self-contained accommodation on the basement that is used by a resident that is independent with living skills. 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted unannounced over two days in June 2007 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedure. During the site visit, the records were examined, a tour of the premises was conducted and feedback sought from individuals and staff. Four completed “Have your say” surveys were received at the Commission from people who use the service. Feedback from relatives and Health and Social Care Professionals was also sought through surveys. One survey was received from a relative and two from health care professionals. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including the AQAA and notified incidences in the home, (Regulation 37’s). This information was used to plan the inspection visit. The four people living at the home were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. The views of the manager, staff and people using the service were gathered either by face- to- face discussions or by surveys. What the service does well: The relative that responded through the survey felt that the service provides choices, security and stability to the people at the home. A health professional stated in the surveys “The service provides a caring individual package. “All clients needs are met and each individual is treated fairly. The home is caring and kind.” 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 6 The comments made by the individuals through face-to-face discussion and surveys were “ I like living here and the staff treat me well.” 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. 45 Mayfield Park North DS0000026563.V340414.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 45 Mayfield Park North DS0000026563.V340414.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides individuals with sufficient information to make decisions about moving into the home. The resident group is stable and vacancies are not expected in the foreseeable future. Further information must be added to the Statement of Purpose about the reasons for the age range and the skills of the staff to meet the age range. EVIDENCE: The home’s Statement of Purpose was recently reviewed to make clear the admission criteria and the age range for potential individuals wishing to live at the home, their representatives and funding agencies. It states that accommodation is mainly offered to people between 50 and 70 years. The manager must make clear the reasons for this age range and the skills of the staff to meet the age range. There are no current vacancies and none expected in the near future. 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Individuals benefit from receiving an individualised and consistent service. In seeking the individuals contributions earlier in the process the care planning process will be enhanced. They can expect to be involved in making decisions about all aspects of their care. Risk assessments must be reviewed with the care plans to ensure that the actions based on the current level of risk. EVIDENCE: Individuals at the home were consulted about their input into the home’s care planning process. Two people stated that the manager compiles the care plan and discusses the content with the person. It was further stated that it was usual for the manger to seek their person permission before the information is included into the care plan. The keyworker on duty confirmed that the manager will usually develop the care pan and staff are given the opportunity to make comments about the plan of action. The manager will then sit with the person and discuss the plan and their permission will be sought to include 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 10 sensitive information within the plan. One “Have your Say” survey was received from a relative, which states that the home always meets the needs of the people at the home. While individuals are involved in the final stage of their care plans, the manager should consider involving individuals in the development of the care plan. Case records are sectioned into personal profiles, care plans, risk management, health, finance and contracts. The manager reviews care plans annually and individuals sign their personal profiles and care plans to indicate their awareness and agreement with the plan of action. The care plans show that individuals living at the home are independent and mainly require emotional support from the staff. It is evident from the review of the case records that a person centred approach to meeting needs is used to write personal profiles and care plans. Preferred routines, likes and dislikes are incorporated into all the information about the person. An Individual Care Programme Approach (ICPA) meeting was held for one person, while the other three individuals have not had an ICPA since 2003, indicating that individuals have enduring mental health care needs. Two individuals at the home giving feedback confirmed that they make their own decisions without staff support. Care plans are specific about the choices made by the persons concerning all aspects of their life. These include interests; spiritual needs, maintaining contact with relatives and health care. The way individuals manage their finances is clearly documented and choices made by the person in respect of finances is detailed. Members of staff say that individuals that become anxious are supported to make decision mainly by sitting with the individuals and talking things through. The persons opinions are sought or the manager will speak to the individuals As the people at the home are able to read and write, accessible formats are not used at the home. Advocacy was discussed with the manager and it was stated that part of the home’s Quality Assurance system is about seeking more input to make decisions. Through the process the need for advocacy would be considered and it was not assessed as necessary at this point. Staff say that the people at the home do not exhibit aggressive or violent behaviours and restrictions are not imposed at the home. Individuals at the home are supported to take responsible risk and where a risk is identified, risk assessments are completed. Individuals ability to use kitchen appliances, leave the home unsupported and be alone in the home is assessed through the risk taking assessment. The individuals capabilities with independence, smoking and mental health care needs is also assessed at the home along with the Control of Substances Hazardous to Health (COSHH) substances. Risk assessments are not currently reviewed with the care plan and must form part of the care planning process. 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 11 The home maintains an accident book and there were no accidents recorded since the last inspection. 45 Mayfield Park North DS0000026563.V340414.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The individuals at the home are supported to pursue their chosen lifestyle and are supported to be part of the local community. There is a clear approach that respects individuality and promotes independence. EVIDENCE: Three people at the home were consulted about the activities that they undertake. One person said “ I do my chores at the home and go to my boyfriends” and two people said “ I like to knit, smoke and drink tea when I am at home.” The individuals interests are specified within their personal profile and care plan. Two people currently attend day care centres, one person recently retired from work and one chooses not to have structured daytime activities. The two people that have structured daytime activities attend the Activity Resource Centre (ARC) three times per week and two pursue their interests and hobbies. Two people enjoy knitting and watching the TV when they are at home and one enjoys bus trips. Two “Have your say” 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 13 surveys were received from health care professionals. One states that the home always supports individuals to live the life they choose and another stated it was usual. Through the survey one person stated “Individuals are encouraged to become socially inclusive in society /community.” Two people are independent with travel and leave the home without staff support and two people must be accompanied outside the home. Individuals at the home use public transport and one person will go out with staff in the evenings and daytrips are organised at weekends. The Statement of Purpose states that outings and holidays will be arranged on request and three people enjoy the organised day trips and pub lunches and two have annual holidays. Relationships form part of the individuals care plans and personal profiles detail the links with family and friends. One person has no input from family and friends, two people have relative input into their care and three have friends involved in their lives. Two people have visitors and one maintains contact by post. The visiting arrangements are specified within the Statement of Purpose, which states that there is open visiting, and can be conducted in private. For one person restrictions are imposed on one visitor and a risk assessment that supports this decision is in place and regularly reviewed. A survey from a relative states that the care home usually assist their relative to keep in touch. There is a visitor’s book and all visitors to the home must specify the date and nature of their visit. The expectation that individuals reach their potential for independence is specified in the range of needs and admission criteria of the Statement of Purpose. House rules are detailed within the Terms and Conditions and relate to paying the fees and respecting others property, the expectations that individuals participate in household chores is listed in the Service User Guide. There is a daily programme for the individuals at the home, it is divided into morning, afternoon and evening routines and include the household tasks that individuals must undertake. Three individuals were consulted about the rules and expectations of the home. One person gave specific examples of personal rules and another person stated their designated household chores, confirming the information in place. Policies and procedures that respect the individuals include the Privacy and Dignity policy and staff Code of Conduct. Individual at the home said that keys are provided, staff use their preferred mode of address and staff knock and wait for an invitation to enter. In terms of the rules of the home it was stated that smoking is permitted in designated areas only, there are no structured times to rise and retire and mail is handed to the person unopened. A Smoking policy was introduced to reflect the recent changes in the law. An Environmental Health Officer (E.H.O) conducted an assessment at the home and the outcome is people can continue smoking in the lounge, with the measure in place. 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 14 The records of food provided show that meals served are requested by the person and generally the staff prepare meals for three people. One person is more independent and prepares light snacks and refreshments in the flat. There is a good range of fresh, frozen and canned goods, which reflect a varied diet. Individuals said that the meals were good and there was enough to eat. 45 Mayfield Park North DS0000026563.V340414.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals can expect sensitive and prompt support for their personal and Health care needs from a skilled staff team. Medication systems are safe. EVIDENCE: One person currently requires personal care support from the staff and another needs to be supervised in/out of the bath while the other individuals are able undertake their personal care without staff support. The personal care of the individuals living at the home are specified within their care plans and state their preferences, routines and the actions to meet the identified need. Bath stools and rails were installed for two people to maintain their levels of independence. One “Have your Say” survey was received from a relative and it states that the home always keeps them informed about important issues affecting their relative. Two professional surveys were received from health care professionals and the GP stated that the home usually meets the individuals heath care needs. The survey from the staff nurse at the resource centre 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 16 states, “ clients at Mayfield Park receive a superb service. Their individuals needs are met and they are happy.” Individuals health care needs are recorded in their personal profiles and health care plans. Each person has a medical profile that describes their health care needs, medication administered and records of visits. It is evident from the record of the visits that individuals access NHS facilities they have regular check ups with the dentist, optician and chiropodists. While personal profiles are up to date for two individuals, the medical profiles must be reviewed for the other two people that live at the home. The member of staff on duty described the actions that staff must take to meet the individuals needs. Members of staff accompany two individuals on health care appointments and two visit their GP’s independently without staff support. One person is a diabetic, which is controlled by diet and oral medication. Screening is offered to the females that live at the home and two have regular screening. The member of staff on duty described the systems such as handovers when shift changes occur and daily records, which ensure medical advice, is followed by the staff. Risk assessments are in place for the three people that self medicate and staff administer medication to one person. Records of administration show that staff sign the records after the medication is administered. Paracetamols are administered when required from a stock supply, a separate record of administration is maintained and the balances cross-referenced with the records of administration. Medication profiles are included in their health care notes and specified is the purpose of the medication and their side effects. 45 Mayfield Park North DS0000026563.V340414.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well maintained and for individuals to continue to benefit from living in a comfortable and clean environment, the manager must continue to maintain the home to an adequate standard. EVIDENCE: Individuals at the home named the members of staff that they would approach with complaints. One person said “Ioan usually sorts it out.” “Have your say” surveys from people at the home state that they know who to speak to if they are not happy and they always know how to make a complaint. The survey from a relative states that they know how to make a complaint and the service has always responded appropriately. The Complaints procedure is included in the Statement of Purpose and Service User Guide. The records of complaints received at the home were examined and show that one complaint was received at the home since the last inspection. The member of staff stated that where concerns are raised about house issues, house meetings are used to discuss these issues. The “No Secrets” guidance, Protection of Vulnerable Adults and the Trust “Do the Right Thing” procedures are available at the home and show a commitment towards safeguarding adults from abuse. Members of staff have attended external Safeguarding Adults courses and the manager states that there are no safeguarding adults referrals pending. 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 18 The member of staff on duty stated that individuals that exhibit violent and aggressive behaviour. 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is well maintained and for individuals to continue to benefit from living in a comfortable and clean environment, the manager must continue to maintain the home to an adequate standard. EVIDENCE: The property has the appearance of a domestic dwelling with level access into the home. It provides accommodation and personal care for four people, arranged over four floors with shared space on the ground floor and bedrooms on the basement and first floor. The third floor is used by staff for sleeping-ins at night. There is a bed-sit, with en-suite on the basement, used by one person living independently. On the first floor there is a double and single room. The property is close to the local shops and bus routes Overall the building is maintained to an adequate standard and clean and since the last inspection, a new porch was fitted and the screen in the sharing room repaired. During the tour of the property it was noted that the lounge carpet 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 20 and chairs is in need of attention. As individuals smoke in the lounge there are burn marks in the carpet and chairs, which must be repaired/replaced to ensure individuals, have a homely environment. The bed-sit in the basement is fully fitted with en-suite, kitchen, sitting and sleeping space. On the first floor there are two bedrooms, two females share one bedroom and the second is single and occupied by another female. Both bedrooms contained a combination of the home’s furniture and individuals personal belongings reflecting their lifestyles. There is a lounge with sufficient seating for four people, a dining room with additional seating and kitchen. Residents have sufficient shared space to sit together and away from others. The residents accommodated are fully ambulant and do not require assistance with moving around the home. The laundry space is adjacent to the kitchen, with floors and walls that can be easily washable. There is a washing machine and tumble dryer that are domestic in scale. The washing machine is designed to reach 90 temperature. “Have your Say” surveys from individuals living at the home state that the home is always clean and fresh. 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living at the home are supported by a competent, qualified and skilled staff team who are well supervised. EVIDENCE: There are three members of staff employed at the home and the personnel files were examined during the site visit. The most recent recruitment is from within the Trust and a completed application form and two written references were held in file. Copies of their Criminal Records Bureau (CRB) disclosures were viewed for all the staff working at the home. Training records were examined and since the last inspection members of staff have attended Mental Health Awareness, medication, diabetes and Safe Guarding Adults training. Members of staff are registered onto NVQ level 3 training. Individuals at the home said they were treated well by the staff and one person stated, “The staff treat me well, they are respectful and know how to care for my needs.” A bank member of staff was consulted about the access to training at the home. It was stated that there is access to statutory 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 22 training, for example fire. The survey from the staff nurse at the resource centre states, “The staff are competent/professional and caring.” 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals can expect to live in a safe environment and can be re-assured that standards will be the subject of ongoing monitoring. EVIDENCE: The manager was consulted about the style of management used to maintain the standards of care at the home. It was stated that a there is a quiet style of management used because it suits the people at the home and it is a quiet stable environment. In terms of the selection of staff, there is an expectation that staff are patient with the people living at the home. Regarding systems that ensure consistency of care to the people living at the home, individual supervision, working “hands-on” provides direct feedback about the provision of care from people at the home and keyworker time ensure consistency is 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 24 maintained. In addition, the manager said that visits from the responsible person, sharing ideas through peer support and operation policy are other means that ensure consistency throughout the Trust. Members of staff and individuals made favourable comments about the style of management and felt that concerns would be taken seriously and acted upon. The Trust has introduced a Quality Assurance audit tool based on the National Minimum Standards (NMS), there is a system of seeking evidence to support the findings and outcomes are recorded in the audit tools. Sources that feedback into the planning and review process for the home includes staff and external service user surveys. Portable appliance checks and gas heating systems are checked annually to ensure a safe environment for the people living at the home. Cash is held in safekeeping on behalf of two people living at the home and records show each transaction, which is signed by the staff and the person and cross-referenced with the cash held. Schedules are provided for each person funded by the Local Authority and the fees are £281.00 for each person currently accommodated. There is a rota in place and one person is rostered on each shift with one person sleeping-in at night. Additional staff are rostered for outings and 1:1 and bank staff are currently used to cover annual leave and sickness. 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x x 3 x 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 26 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. 2. Standard YA1 YA9 Regulation 6 13 (4) (b) Requirement The Statement of Purpose must be reviewed to make clear the reasons for the age range. Risk assessments must be kept under review to ensure that the actions are consistent with the current level of risk. The lounge carpet and chairs require repair/replacement. Timescale for action 30/01/08 30/10/07 3. YA24 23(2) (d) 30/12/07 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 Refer to Standard YA6 Good Practice Recommendations The manager should consider seeking individuals contributions earlier in the care planning process. 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 45 Mayfield Park North DS0000026563.V340414.R01.S.doc Version 5.2 Page 28 - 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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