Inspection on 15/05/05 for 46 Derby Road

This inspection was carried out on 15th May 2005.

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 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

46 Derby Road 28/06/06

46 Derby Road 06/01/06

46 Derby Road 07/06/05

46 Derby Road 24/06/04

46 Derby Road 08/12/03

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

CARE HOME ADULTS 18-65 46 Derby Road, Burton On Trent Staffordshire DE14 1RP Lead Inspector Mrs Mandy Brassington Key Unannounced Inspection 15 May 2007 09:15 46 Derby Road, DS0000004931.V338063.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 46 Derby Road, DS0000004931.V338063.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. 46 Derby Road, DS0000004931.V338063.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 46 Derby Road, Address Burton On Trent Staffordshire DE14 1RP 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) 01283 536290 Robinia Care Homes (2) Limited Vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 46 Derby Road, DS0000004931.V338063.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2006 Brief Description of the Service: 46 Derby Road is a large period semi-detached property situated in a residential part of Burton on Trent and does not present as a care setting. The home is within easy walking distances of local amenities and with good links to public transport. The house is set back from the main road and has parking spaces at the rear, which is accessed by drive to the side of the house. The building is on two floors and comprises; three bedrooms (1 en-suite shower), an office, sleeping in room, lounge, dining/activity room, kitchen, on bathroom with shower, and one separate toilet, laundry room and storage. The home is not suitable for any person with a severe physical disability. There is a garden at the front and rear, and a useful patio area at the rear. The home is registered to provide accommodation for three individuals with a learning disability. The home promotes independence and the development of social skills and individuals are able to take an active role in the daily management of the home. The home provides a minimum of two staff on duty at all times to meet the complex needs of individuals resident in the home. The manager informed the Commission for Social Care Inspection that the current fee level in the home is between £118,060 and £132,463. 46 Derby Road, DS0000004931.V338063.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was an unannounced key inspection and therefore covered all of the core standards. The inspection took place over 6 hours by one inspector who used the National Minimum Standards for Younger Adults as the basis for the inspection. A tour of the home was undertaken. On the day of the inspection, the home was accommodating three people. The inspection included an examination of records, indirect observation, discussion with three service users, the proposed care manager and three staff on duty. Case tracking of three care plans was undertaken. Three staff records were examined and observation of daily events took place. The inspector observed a member of staff administer medication, and inspected the storage system and medication procedures. The proposed care manager had completed an Annual Quality Assurance Audit (AQAA) prior to the inspection. What the service does well: Being small in registration, the home is able to provide a homely and friendly environment. People who use the service are able to personalise the home and participate in ordinary domestic activities. Plans of care include assessments of risk for activities in the home and the community. Staff promote individuals right to take responsible risks on a daily basis. Individuals are able to access a wide variety of work and leisure pursuits of their choosing, and are able to develop relationships with other residents and people from the local community. The manager and staff hold strong values around the support and care needs within the home to provide a good quality service. The staff have open and positive relationships with people who use the service and are aware of individuals needs, and how to manage complex behaviour. Staff have completed training for managing complex behaviour and work together and are aware of the agreed interventions. 46 Derby Road, DS0000004931.V338063.R01.S.doc Version 5.2 Page 6 The development of good relationships and the knowledge of individuals needs, has enable the staff team to work closely with the people who use the service, to reduce the number of incidents around complex behaviours. The home has a staff group that is balanced and diverse to enable individuals a choice of male or female staff, and the staff team are of varying ages. Feedback received from service users included: ‘The staff help me’ ‘All the staff are nice, they talk to me a lot’ ‘the staff help me do my jobs’ ‘the staff are funny, we have good fun here’. What has improved since the last inspection? What they could do better: The plans of care are detailed and person centred. Service users confirmed they were involved in the planning and review process, although the new formats did not record this. Evidence of service user involvement should be recorded within the plan and all relevant documentation. Robinia are in the process of implementing a number of new formats for preassessments and person centred planning. The organisation needs to ensure that staff have suitable training to ensure these are suitably completed and used appropriately, as with the pre-assessment assessment. There are comprehensive Policies and Procedures available for staff to ensure the health and welfare of staff and service users. These should be reviewed on a regular basis to ensure they reflect current practice and any changes to legislation or ‘best practice’. 46 Derby Road, DS0000004931.V338063.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. 46 Derby Road, DS0000004931.V338063.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 46 Derby Road, DS0000004931.V338063.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, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a Statement of Purpose that is specific to the individual home and sets out the objectives and philosophy of the service supported by a Service user Guide. Admissions are not made to the home until a full needs assessment has been undertaken. The assessment involves the individual, and their family or representative, where appropriate. EVIDENCE: The home accommodates three individuals, all of whom have lived in the home for over two years. Discussion with the manager revealed that an assessment is carried out to ensure the home is able to meet the needs of the individual. Robinia have recently introduced a new Pre-placement assessment. This document was very detailed and enables the assessor to gain a wide range of knowledge and information about the needs of the individual. For two individuals this document has been completed and replaced the original preplacement assessment. This was discussed with the manager regarding whether it was appropriate to complete this assessment, as the service users 46 Derby Road, DS0000004931.V338063.R01.S.doc Version 5.2 Page 10 had been living in the home for a considerable length of time; the information relates to pre-placement not a re-assessment of needs. It is recommended that this practice be reviewed. Inspection of records revealed that people who use the service have an individual contract with Robinia referring to the terms and Conditions within the Service user Guide and includes a record of fees. 46 Derby Road, DS0000004931.V338063.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, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home involves individuals in the planning of care that and quality of life. Each plan of care includes a assessment, which is reviewed regularly. Management addressing safety issues whilst aiming for better quality of affects their lifestyle comprehensive risk of risk is positive, life. EVIDENCE: 46 Derby Road, DS0000004931.V338063.R01.S.doc Version 5.2 Page 12 All individuals had a plan of care that could easily be used by all staff and people who would not be familiar with the format. The plans of care included personal information relating to individual’s aspirations, the one to one support provided and agreed times where individuals were able to be independent in the community. Each person had a weekly planner for agreed activities in the home and community. These were written and in pictorial format; all individuals reported that they had a copy in their room. One individual had a daily planner that he was able to refer to. Staff reported that this structured programme of activities had reduced levels of anxiety. Assessments of risk were completed where appropriate for individuals who may abscond; self harm or exhibit complex behaviours. Where any behaviour had been identified, detailed behavioural management programmes were recorded that included the background, proactive strategies, de-escalation techniques, crisis intervention and the process involved in the recovery stage. Discussion with staff and examination of records of incidents, confirmed that the frequency of incidents had decreased, and staff were able to use agreed techniques to reduce or prevent aggressive or abusive behaviour. Plans of care were reviewed when required and formally on a six monthly basis. A copy of the review was available on file and included service users views. Individuals confirmed they were present at reviews and supported to contribute to the review process. The plans of care and review documentation did not include evidence of service user involvement. It is recommended that this be recorded. From discussion with staff and observation of practices it was evident that people who use the service are in control of their lives and are supported to make informed decisions and to take responsible risks. 46 Derby Road, DS0000004931.V338063.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, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are involved in meaningful daytime activities of their own choice and according to their individual interests. Individuals have the opportunity to develop and maintain important personal and family relationships People who use services are involved in the domestic routines of the home, The staff have a commitment to enabling people who use services to develop their skills, identify their goals, and work to achieve them. EVIDENCE: 46 Derby Road, DS0000004931.V338063.R01.S.doc Version 5.2 Page 14 People who use the service are encouraged and supported to take risks as part of an independent lifestyle; plans of care include assessment of risk for activities within the home and the community. In line with identified needs of people who use the service a weekly planner is completed with individuals on a Sunday and records all agreed activities for each day. One person who used the service was very specific about the timing of the planner and the staff recognised the need to complete this in a timely manner to reduce anxiety. Individuals were involved in meaningful activities according to their interests. Discussion with people who used the service and staff revealed that usual activities included bowling, swimming, shopping, watching and attending local football matches, going to local pubs and eating meals out, and horse riding. The staff were committed to enabling individuals to participate in community activities and in domestic routines of the home. Two individuals attend a local college on a part time basis. Individuals reported they are involved in the ‘Learning for Life programme’ and a copy of the learning agreement with the college was included within the plan of care. One individual had a job delivering newspapers in the local area. Discussion revealed he was proud of his work and committed to completing all deliveries. Holidays were planned for each service user for the summer; two people have chosen to go to Butlins and one person is going to Disney Land Paris. People who use the service are supported to maintain good relationships with family members and friends. One individual stays with family members once a month. One person recently experienced a bereavement of a close relative and the staff have supported the individual to put together a book of photographs, letters and memories. Staff reported that this has been helpful and supported the person. People who use the service are involved in the planning, preparation and cooking of meals. One individual spoke at length about healthy eating and choosing healthy meals’ ‘I eat lots of fruit, and have one treat in the week. You have to be careful what you eat to stay healthy.’ 46 Derby Road, DS0000004931.V338063.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, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is responsive to the individual needs and preferences of the people who use service, and staff provide personal care that is flexible, consistent, and person centred. People who use services have access to healthcare and specialist services to meet individual complex needs. EVIDENCE: All three plans of care were examined and the plans recorded information relating to health appointments including visits to the Doctors, Dentist, Chiropody and opticians. Included was a detail of any outcomes of meetings. People who use the service receive specialist intervention from the Densy Partnership, who provide support with individual’s complex needs, and support staff with the intervention of agreed strategies to manage behaviour. 46 Derby Road, DS0000004931.V338063.R01.S.doc Version 5.2 Page 16 Individuals spoke highly of the support provided by staff and examination of records and information received in required notifications, demonstrated that there had been very few incidents of abusive and aggressive behaviour due to the consistent positive approach from staff. The Monitored Dosage System for medication (MDS) is used within the home. Suitable policies and procedures for medication were in place. Staff had received training for safe administration of medication and the medication file contained details of trained staff along with their signature and initials used on the Medication Administration Record (MAR). The medication file contained details of how individuals liked to take their medication and included the usual usage of any drug, along with possible side effects. Discussion with staff on duty revealed a good knowledge of safe procedures in the home. The Medication Administration Record included a photograph of the person. Suitable protocols for administration of ‘as required’ (p.r.n) medication was included and staff were aware of these. All individuals had a homely remedy form on file signed by a General Practitioner. As part of the quality assurance system, a senior member of staff carries out a monthly audit of medication and maintains a record. 46 Derby Road, DS0000004931.V338063.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, 23. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has an open culture that allows individuals to express their views, and concerns. There is a complaints procedure that is clearly written and easy to understand using pictorial symbols. Training of staff in the area of protection is provided along with other training around dealing with physical and verbal aggression to ensure the safety of all individuals and staff members. EVIDENCE: The home has a copy of the complaints procedure within the Service User Guide, which is also in pictorial form. Individuals have a copy of the procedure in their bedroom. The home maintains a copy of any complaint or concern raised with a detail of any outcomes. One service user reported that he had raised a concern, ‘I tell the staff if I am unhappy, they make things right’. A record of the concern had been logged and the service user clearly stated he was aware of how this had been dealt with and was happy with the outcome. 46 Derby Road, DS0000004931.V338063.R01.S.doc Version 5.2 Page 18 Policies and Procedures for Safeguarding adults were in place and discussion with staff revealed training had been provided. Staff revealed they were aware of the procedure and how to respond to an alert. Examination of records and discussion with staff revealed training around dealing with physical and verbal aggression had been received. Plans of care recorded detailed information regarding how to respond to any complex behaviour. Examination of financial records demonstrated people who use the service are included in all transactions and a member of staff and the individual sign all transactions. Accounts were balanced and accurate. 46 Derby Road, DS0000004931.V338063.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): 24, 25, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides for the individual requirements of the people who use the service and the living environment is appropriate for the particular lifestyle and needs of the individuals. The home is clean, safe and comfortable and well maintained and people who use the service are able to personalise their rooms to reflect individual interests. EVIDENCE: The home is an ordinary semidetached house, indistinguishable from other homes in the area. The property is well maintained to a good standard. 46 Derby Road, DS0000004931.V338063.R01.S.doc Version 5.2 Page 20 The home consists of a shared lounge, large dining area, kitchen and utility room on the ground floor and a bathroom with shower, laundry room and office on the first floor. There is one en-suite bedroom on the ground floor and two bedrooms on the first floor. All individuals residing in the home were pleased to be able to show their bedrooms as part of the inspection. Individuals reported they were able to decorate and personalise their bedrooms to reflect their interests. One bedroom has many posters of football teams and one room had an extensive collection of vehicles. To the rear of the property there is a patio and garden area. Staff reported that individuals had been involved in redesigning the garden and had won a prize within the Company for their work. 46 Derby Road, DS0000004931.V338063.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): 32, 34, 35, 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has suitable staffing levels to meet the needs of the people using the service. The staffing of the home is based around delivering outcomes for the people using the service. The service puts a high level of importance on training and staff are supported through training to meet the individual needs of people using the service. EVIDENCE: Staff reported that shifts are flexible and are organised around the needs and planned activities of the people who use the service. In general, there are three staff on duty throughout the day and a night staff and sleep in person during the night. On the day of the inspection the following staff were on duty:1 Team leader – 7.30am –3.30pm 1 Support worker – 9.30am –2.30pm 1 support worker – 7.30am –2.30pm 46 Derby Road, DS0000004931.V338063.R01.S.doc Version 5.2 Page 22 During the afternoon 1 Team leader – 3.00pm – 10.30pm 1 Support worker – 2.30pm – 9.30pm 1 Support worker – 3.00pm – 9.00pm Inspection of records and discussion with staff revealed that training has been provided for Safeguarding Adults, Communication, Autism, Fire training and Makaton. The manager reported that all staff have received the required updates for Health and Safety and Moving and Handling. Staff spoke highly of the training opportunities provided by the organisation. The home has a staff group that is balanced and diverse to enable individuals a choice of male or female staff, and the staff team are of varying ages. Staff have a supervision agreement and agreed action plan, and supervision is conducted bi-monthly. Staff meetings are conducted bi-monthly and a copy of the minutes is recorded. The home demonstrated there are robust recruitment procedures in place to safeguard individuals. Staff records included a photograph, copy of identity, an application form, two references and evidence of Criminal Records Checks (CRB). The manager reported Robinia carry out Criminal Record Checks for Staff every three years. This is considered good practice. Discussion with people who use the service revealed they felt safe and supported at the home and comments regarding the staff included: ‘The staff help me’ ‘All the staff are nice, they talk to me a lot’ ‘the staff help me do my jobs’ ‘the staff are funny, we have good fun here’. 46 Derby Road, DS0000004931.V338063.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): 37, 38, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager communicates a clear sense of direction and is able to evidence a good understanding and knowledge of individual’s needs and the support required. The health, safety and welfare of staff and people who use the service were protected and appropriate maintenance work and annual checks have been carried out. EVIDENCE: 46 Derby Road, DS0000004931.V338063.R01.S.doc Version 5.2 Page 24 The proposed care manager has submitted a Criminal Records Check (CRB) with the Commission, and in line with guidance has prepared the application to submit upon suitable CRB clearance. The manager was on Annual leave on the day of the inspection but chose to participate in part of the inspection process. Discussion with the manager demonstrated a commitment to the home and developing the service. Staff reported that they received support and guidance from the manager and were positive regarding the developments in the home, to ensure a quality service was provided. Discussion with people who use the service revealed the manager was always available, participated in daily activities, and dealt with any concerns. One individual stated ‘ Mandy is funny, ten out of ten for Mandy.’ Robinia carry out an Annual Quality Audit and complete an action plan from the results. The Audit is linked to the Outcomes of the National Minimum Standards. Key workers complete quality audits with the people who use the service. The forms have been developed using pictorial pictures and symbols. Staff reported that this is linked to the annual review. The health, safety and welfare of staff and service users were protected. Information within the home and recorded on the Annual Quality Audit Questionnaire (AQAA) sent by the Commission, demonstrated the registered person had ensured that all maintenance work, repairs, annual checks, testing of equipment and regular fire drills are undertaken. Required checks have included: Annual Gas Safety Test was conducted in May 2006. Portable appliance tests were carried out in January 2007 Water temperatures are carried out monthly Fridge and freezer temperatures are recorded daily Fire Equipment was serviced in June 2006 Suitable Fire equipment checks, evacuations and training had been carried out. Robinia have a large range of policies and procedures suitable for the home. The home has demonstrated it is able to respond and develop to the needs of the people who use the service. It is therefore good practice to review the home’s policies and procedures and evidence this, to ensure they meet current practice and changes in legislation; a number of policies date back to 2000. 46 Derby Road, DS0000004931.V338063.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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 X 3 3 3 X X 3 X 46 Derby Road, DS0000004931.V338063.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard YA2 YA6 YA40 Good Practice Recommendations The pre-placement assessment should not be completed for individuals already living in the home. Evidence of service user involvement to be included within the plan of care Policies and procedures should be regularly reviewed to ensure they reflect current practice. 46 Derby Road, DS0000004931.V338063.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 46 Derby Road, DS0000004931.V338063.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. 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!