Inspection on 15/06/05 for 48 Burton Road

This inspection was carried out on 15th June 2005.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

48 Burton Road 25/02/09

48 Burton Road 11/02/08

48 Burton Road 26/07/07

48 Burton Road 07/01/06

48 Burton Road 12/02/05

48 Burton Road 11/08/04

48 Burton Road 27/10/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 48 Burton Road 48 Burton Road Branston Burton-on-Trent DE14 3DN Lead Inspector Wendy Jones Announced 15 June 2005 time here 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 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 Stationary 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. 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 48 Burton Road Address 48 Burton Road Telephone number Fax number Email 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 545370 01283 545370 Robinia Care Homes (2) Limited Mrs Denise Jane Flanagan Care Home 4 Category(ies) of Learning Disability (4) registration, with number of places 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 12 February 2005 Brief Description of the Service: The service is registered to provided 24 hour support and care for four younger adults with a learnining disability. The period is a period semi-detached house located in the residential area of Branston, on the out skirts of Burton- onTrent. The home is conveniently situated close to a town, on a bus route and close to shops and amenities. The premises are set back from the main road and have tall metal gates leading to the gravel frontage and drive. The building is on three floors and comprises; four bedrooms, an office/sleep in room, lounge, dining/activity room, bathroom and toilet facilities, laundry room and additional storage. One of the bedrooms has an en-suite shower and toilet facility. Parking space is adequate, to the rear of the house is a large garden and patio area. 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out on 15th June 2005. The inspection methodology included discussion with the manager, interview of one staff, conversation with two care staff and one service user, discussion with a relative and social worker; observation of interactions between service users and staff; from information provided in the pre inspection questionnaire, care records, staff rota’s, policies and procedures, Statement of Purpose and Service User Guide, recruitment records, financial records. The service is registered to provide 24-hour care for service users under 65 years who have a Learning Disability. At the time of inspection three service users occupied the home, all were reported to have severe learning disabilities, Autism Spectrum Disorders, communication difficulties and could display some behaviours that challenged the service. Positive feedback was received from a relative and social worker. What the service does well: The service has produced information for service users in pictorial form the Statement of Purpose and Service user Guide provided prospective service users and their supporters with the information they needed to enable them decide if the service could meet assessed needs. Assessment and care planning was of good quality, with action plans devised for every assessed need. Detailed 24 hour plans of care identified each service users preferred routine and the assistance they required to make day-to-day decisions. Guidelines were in place for staff to follow for the management of challenging behaviour. Reviews of care plans were undertaken regularly with a formal 6 monthly review that included input from family and supporters of service users. Efforts had been made to structure service users day, to provide a range of social and recreational opportunities in and out of the home. Medication systems were well established, records appropriately maintained, stock control methods effective. Service users were encouraged to be involved in day-to-day decision-making; a number of visual tools were used to assist them, i.e. pictorial timetables and menus. 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 Page 6 The staff team was well established, with no vacancies reported, staffing levels were reflective of the needs of service users, and there was a mixed gender staff group. Induction programme for staff met the minimum standards and ensures staff had a good foundation. Mandatory training was provided; the organisation had a rolling programme of training sessions. Regular servicing of fire safety and electrical equipment had been undertaken, monthly monitoring of hot water temperatures were recorded. Risk assessments were in place, for individuals and generally. What has improved since the last inspection? What they could do better: A review of the Statement of Purpose must be undertaken to ensure that it accurately reflects the staffing and staff training. Service users should be supported to find suitable educational and occupational opportunities. A review of the finance policy and procedure should be undertaken, staff must ensure that they follow procedures and check balances at handover, and service user must be reimbursed for any staff expenses they have paid for. Regular audits of service users monies should be undertaken. An annual Quality Assurance Development plan must be produced, the outcome of any Quality review audit must be circulated to service users the CSCI and other stakeholders. A resolution must be sought to the impasse around access to, and funding for speech therapy services. The service should liaise with the placing social worker and service users supporters regarding the funding of private chiropody care. The service must ensure that all staff have received annual fire safety training and 50 of the staff team should be trained to NVQ level 2. Staff records must include a staff photograph. 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 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. 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 The homes Statement of Purpose and Service User Guide were good, providing service users and prospective service users with details of the services the home provides enabling an informed decision about admission to be made. Assessment documentation was comprehensive detailing all of the service users needs. Transitional arrangements for prospective service users included visits to the home, overnight stay’s, compatibility testing and a trial period. Contracts included the terms and conditions of residency. EVIDENCE: The service had a Statement of Purpose and Service User Guide, both were provided for inspection purposes. The Service user guide had been produced in a user-friendly pictorial format. It was established that the Statement of Purpose must be reviewed to ensure that it accurately reflects the current staff team and staff qualifications. From the sample of care records inspected, there was evidence of a Community Care Assessment carried out by the placing social worker. It was understood that a senior manager within the organisation (Robinia) carries out initial assessments. If at that stage it is felt that the needs of a prospective service user can be met, the care manager of the service becomes involved 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 Page 10 with more detailed assessment. The usual procedure includes opportunities to visit the service and for overnight stay’s where suitability and compatibility with the other service users is tested and assessed. A written contract was included in the individual care files of service users; terms and conditions of residency were detailed in the contract and in the Service User Guide. 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9. The standard of care planning was high, ensuring that the needs of service users were met. The quality of risk assessment was high with evidence that regular reviews ensured that service users were cared for appropriately. Information was available in a suitable format to enable service users to make informed decision about their lives and lifestyles. EVIDENCE: The care planning model was called Essential Life Planning adhered to the principles of Person Centred Planning, which is firmly established as the model for use in Learning Disability Services, as it places the service user at the centre of the plan, and where possible must be service user lead. The records included a detailed personal history, records of each service users preferred routine including rising and retiring times, involvement in day to day activities and the assistance and support they required to undertake personal care, to access activities, to make decisions. 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 Page 12 The samples of care plans seen were based upon comprehensive assessment and were subject to regular review. There were explicit guidelines for staff to follow in the management of challenging behaviour Risk assessments were in place for individuals and had been reviewed regularly. There was evidence that the service was committed to supporting service users to make informed decisions about their daily lives. Pictorial timetables ensured that service users knew what they was available to them on a daily basis, giving the necessary structure to the day, particularly important for service users who have an Autistic Spectrum Disorder. Key workers were allocated to ensure that care and support was consistent. 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,14,15,17. Service users were supported to maintain links with families and friends within the parameters agreed in the care plans. Service users had recreational and leisure opportunities in a variety of settings. Dietary needs of service users were known and understood and efforts were being made to provide a balanced and varied selection of food to ensure a good nutritional intake. EVIDENCE: All service user retained links with family members, staff supported regular telephone, or written communication with them. Visit to family homes are facilitated as agreed with individuals. Service user timetables indicated that the access to occupational and educational activities was limited, the focus of life appeared from the records to focus on leisure and recreational activities, in both segregated and nonsegregated settings. Activities included shopping trips, visits to local parks and the countryside, swimming sessions. Structured activities included an art therapy session at another of the Robinia care homes and two-service users 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 Page 14 attend a music therapy session at a local church hall. All service users go to a horse drawn carriage class. All service users were reported to have enjoyed a holiday last summer and arrangements were being made to find a suitable holiday for this summer. Menu’s were reported to be planned on a weekly basis with service users, each service user is encouraged to make a choice of two evening meals per week and are involved in the shopping for ingredients, preparation and cooking the meal. A file with pictures of foodstuffs and meals had been created to assist service users to make informed choices. Meal times were flexible around the daily routines of services users. One service user was known to have different cultural dietary preferences; the menu records showed that he had the opportunity to select meals of his choice. 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20. The personal and healthcare needs of service users were adequately met. The medication at this home is well managed promoting good health. EVIDENCE: Records seen, indicated that service users were supported to attend health appointments. Routine dental, GP and chiropody treatment was recorded, service users are registered with a private chiropodist, it was not clear from the information available or from discussion with the care manager if service users health needs required the level of input provided or if their supporters had agreed to privately fund this service. The manager stated that it was service that they enjoyed and that the appointments included nail, foot care and foot massage. Two service users had communication difficulties, using non-verbal methods of communication like Makaton or gestures to make their needs known. It was established from discussion, that speech therapy had been provided at one point with some positive outcomes. It was understood, that access to this service has ceased due to some conflict between the provider and funding authority regarding payment for the service. The organisation must resolve this matter to ensure that service users are afforded all the assistance possible to improve their communication. 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 Page 16 One service user had attended the Accident and Emergency department of the local hospital in the twelve months prior to the inspection. Health needs were monitored on a monthly basis including weight, continence and epilepsy monitoring. Community Learning Disability nurse input was provided in conjunction with Consultant Neurologist. There was no evidence in the records that service users had received preventative health checks, such as well man checks. The systems for the administration of medication were effective, a policy and procedure was in place, the storage of medication was appropriate. Protocols were in place for the administration of as required medication. The service uses a monitored dose system to administer medication, none of the service users self medicate. Team leaders and the manager are responsible for medication and were reported to have undertaken certificated training in the safe administration of medication. The manager stated each of the staff had been assessed as competent. It was suggested that a records of staff signatures and initials is retained in the medication file. 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23. The home had a satisfactory complaints system with evidence that any complaints are responded to and acted upon. Arrangements for protecting service users were satisfactory protecting them from possible risk of harm or abuse. EVIDENCE: A complaints procedure was displayed in the home and information on how to complain had been produced in a pictorial format for the benefit of service users. The information in the pre inspection questionnaire indicated that 16 complaints had been received at the home during the twelve months prior to this inspection. The records showed that the last complaint had been received in January 2005, when a neighbour had complained about car parking, the records showed how the complaints had been acted upon. The care manager reported that the majority of complaints received were related to a service user who was no longer at the home. A relative confirmed that they had been provided with information on how to complain, but had no concerns about the care her relative received. A procedure was in place for staff to refer to should they suspect abuse of service users; in addition the service had a Whistle-blowing procedure. Staff training in Vulnerable Adults matters was provided during the rolling programme of induction, other staff could access this training. Since the last inspection most staff have received Vulnerable Adults procedure training others are enrolled on the training. 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,27,28,30. Recent investment has significantly improved the appearance of this home creating a comfortable, clean and safe environment for those living there and visiting. EVIDENCE: Accommodation was provided over three floors; a lounge, dining room, kitchen and toilet were located on the ground floor. The first floor had three bedrooms all with wash hand basins; a bathroom, laundry and a staff sleep in/office. The top floor had the largest of the four bedrooms. An emergency call system had been fitted; call points were located at various points throughout the home. Windows on the first and second floor were fitted with restrictors. Since the last inspection the home has been redecorated, with the exception of two bedrooms and the laundry area. The manager stated that a new threepiece suite had been ordered to replace the one currently in the home. In addition some dining room furniture had also been ordered to replace the storage units that had been damaged. It was hoped that additional homely touches, i.e. ornaments, plants and pictures could be purchased to ensure that the dining room and lounge appear more homely. 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 Page 19 The kitchen was spacious, well organised with adequate storage and equipment. The laundry room was located on the first floor, was compact, and functional, staff stated that service users were supported to wash and dry their own personal laundry. A sample of bedrooms was seen, the care manager confirmed from the room sizes recorded in the homes Statement of Purpose that bedroom sizes exceeded the National Minimum Standards. One of the bedrooms had en-suite shower and toilet facilities. A service user confirmed that he had been involved with selecting the colour scheme for his bedroom. The home was clean and tidy throughout. 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,34,35,36. Staffing levels were good, providing staff in sufficient numbers to ensure service users needs were met. Numbers of NVQ trained staff did not meet the minimum standards. The arrangements for the induction of staff are good with the staff demonstrating a clear understanding of their roles. EVIDENCE: Service user dependency was described as high, using the residential forum dependency assessment. Weekly care and management hours provided were recorded as 385; these hours were confirmed from the sample of two months staff rotas. Staffing levels for the day of inspection included the manager who was supernumerary 7.30am-6pm, a team leader 8am-4pm, 2 care staff from 7.30m-3pm and 10.30am-6pm respectively. Two staff were allocated from 2.30pm-10pm, one of whom was sleeping in. A waking night staff was deployed from 9.45pm-7.45am. No vacancies were reported and staff turnover had been low since the last inspection. Information in the pre inspection questionnaire indicated that bank/agency staff had staffed 23 shifts. 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 Page 21 A sample of staff recruitment files were seen, there was evidence that two written references had been sought, that applications gave a full work history and staff had been required to provide evidence of qualification. A records of interview questions and responses was on file, with scoring system to ensure that Equal Opportunity requirements were met; matters arising included the need to ensure that photographs of staff are available, that the service ensures that the current records of police clearance for overseas staff is adequate. Care staff totalled 12, 2 of whom were reported to have achieved NVQ level 3; another carer had achieved a Diploma in Health and Social care. The care manger reported that she had NVQ level 3 and was undertaking NVQ level 4. The service currently does not meet the minimum standard of 50 of the work force to be trained at NVQ level 2 by 2005. The service induction was reported to meet TOPPS and LDAF standards, with a 6 week basic induction and a 6 month foundation programme, two new staff were undertaking the training at the time of inspection. The service standard for monthly supervisions had not been met due to pressures of work, the care manager identified some gaps, but records showed that the National minimum Standards of 6 supervision sessions in twelvemonth period had been met. The manager indicated that some team leaders had undertaken training in the supervision of staff and would be delegated the responsibility of supervising some care workers. The manager reported that mandatory training such as fire safety, basic food hygiene was up to date, or had been planned. Records showed that some staff had not received annual fire training. An interview with one member of the staff team confirmed that staff training opportunities had improved and that mandatory training had been undertaken. Other training undertaken included Makaton training. Staff had attended a three-day Securicare training, to provide them with the skills to recognise the triggers to challenging behaviour, how to divert challenging behaviour and how to effectively respond to aggressive behaviour. It was not established on this occasion of the type of training provided meets the guidance or is accredited with the British Institute for Learning Disabilities. 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,40,42,43. The management of the home was adequate, providing clear leadership, for a smooth running and effective service. EVIDENCE: The care manager had been approved as a fit person by the CSCI; she reported that she had almost completed NVQ level 4 in care and management. Information in the pre inspection questionnaire indicated that servicing of equipment such as Gas, Electrical, Fire safety equipment was up to date. A sample of the relevant documentation confirmed this to be the case. Weekly health and safety checks were carried out, with monthly checks of hot water temperatures. Fire alarms were tested weekly, emergency lighting and fire fighting equipment checks carried out monthly, a fire safety risk assessment was in place and had been reviewed, matters arising include a recommendation that the names of staff involved with fire drills is recorded, to ensure that each member of staff participates in at least two fire drills per year. Annual fire safety training must 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 Page 23 be provide for each staff, and a protocol for the safety of a service user who can become uncooperative when the fire alarm sounds should be agreed with local fire officers. Quality monitoring systems must be developed and implemented. A Quality assurance development plan must be in place. It was accepted that monthly Regulation 26 visits have been carried out. A requirement of the inspection was for an audit of service users finances to be undertaken. The manager had reported that some service users had receipts for items they should not have paid for, according to company policy; this was confirmed from the records seen. The company must ensure that service users are reimbursed for such purchases. In addition it was of concern that finances, were not properly checked at handover, again according to policy. The manager also reported that monthly internal checks of monies were planned; the records showed that monthly checks had not taken place as frequently as described. It was required that staff have an opportunity to receive a refresher of the finance policy or that the policy is revised. The scale of charges for service users was reported to be from £98,000£117,000 per year, which includes funding for 25 hours per week 1:1 staffing for each service user. 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 4 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 3 x 3 Standard No 11 12 13 14 15 16 17 x 2 x 3 3 x 3 Standard No 31 32 33 34 35 36 Score x 2 x 2 1 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 48 Burton Road Score 3 2 3 x Standard No 37 38 39 40 41 42 43 Score 3 x x 2 x 3 2 E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 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 YA1 Regulation 6 Requirement Areview of the Statement of Purpose must be undertaken to ensureit accurately relects the staffing and staff qualifications. The service must ensure that service users monies are properly managed, accounted for and recorded, Arrangement to reimburse service users must be made. Evidence of a Quality review and development plan msut be provided. The service must facilitate service users access to specialist health services. Staff must receive annual fire safety training. Photgraphs of staff must be retained in the service. Timescale for action 14/07/05 2. YA12 25(3)(a) 21/06/05 3. 4. 5. 6. 39 19 42 34 24, 13 23(4) 7schedule 2 14/09/05 14/09/05 14/09/05 14/07/05 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 12 Good Practice Recommendations The service should support service users to access suitable E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 Page 26 48 Burton Road 2. 3. 19 42 occupational and educational opportunities. The service should liaise with the placing authority regarding the funding of private chiropody. Records of the names of staff attending fire drills should be maintained. 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 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 48 Burton Road E09 E51 S4923 48 Burton Road V234751 250505 Stage 4.doc Version 1.30 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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