Inspection on 12/07/07 for 5 Barth Close (Royal Mencap Society)

This inspection was carried out on 12th July 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

5 Barth Close (Royal Mencap... 10/07/06

5 Barth Close (Royal Mencap... 27/09/05

5 Barth Close (Royal Mencap... 21/06/05

5 Barth Close (Royal Mencap... 16/12/04

5 Barth Close (Royal Mencap... 12/08/04

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

CARE HOME ADULTS 18-65 Barth Close, 5 (Royal Mencap Society) 5 Barth Close Great Oakley Corby Northants NN18 8LU Lead Inspector Kathy Jones Key Unannounced Inspection 12th July 2007 02:30 Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.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 Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.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. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Barth Close, 5 (Royal Mencap Society) Address 5 Barth Close Great Oakley Corby Northants NN18 8LU 01536 460718 01536 741204 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) Royal Mencap Society Mrs Amanda McQueenie Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service user numbers: No one falling within the category LD may be admitted into 5 Barth Close where there are 5 persons of category LD already accommodated within this home. Date of last inspection 2nd November 2006 Brief Description of the Service: The home 5 Barth Close provides personal care and accommodation for 5 younger adults within the category of Learning Disability. The building is rented from a housing association with the home and the services provided being managed by the MENCAP organisation. 5 Barth Close is located within the Great Oakley residential area of the town of Corby and is adjacent to a health centre with pharmacy and close to a national superstore. The home was newly purpose built and opened in April 2000 and is indistinguishable in design from other houses in the area. All the rooms within the home are for single occupation and without en-suite facilities. Communal areas consist of a small lounge and a kitchen with a small dining area. The garden is large in comparison with similar private residential properties in the immediate area. At the time of this inspection the fees charged to funding bodies ranged between £712.47 and £975.62 per week dependent on assessed need. In addition to these fees, residents pay between £62.97 and £76.15 per week. The fees include personal care, accommodation, meals, laundry and a seven day holiday. Additional charges include chiropody, toiletries, clothing and travel. Information about the services provided including the complaints procedure is available in the office. This includes the statement of purpose, which as detailed in the body of this report has some pictures to aid understanding and is being developed to make it more accessible to residents’. A copy of the last inspection report is also available. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Standards identified as ‘key’ standards and highlighted through the report were inspected. The key standards are those considered by the Commission to have a particular impact on outcomes for residents. Inspection of the standards was achieved through review of the information held by the Commission for Social Care Inspection as part of the pre-inspection planning and an unannounced inspection visit to the service. The pre-inspection planning was carried out over the period of a day and involved reviewing the service history, which details all contact with the home including notifications of events reported by the home, telephone calls, letters, and details of any complaints and concerns received. The report from the last key inspection carried out on 10 July 2006 was reviewed. In view of the concerns identified at the inspection in July 2006, an additional inspection visit was carried out in November 2006 to check compliance with requirements that had been made. The findings of both inspection visits have been taken into account when planning this inspection. This inspection visit was unannounced and covered the late afternoon and early evening period. As residents’ are usually out at day centre the inspection was planned to coincide with their return. The inspection was carried out by ‘case tracking’ which involves selecting residents’ and tracking their care and experiences through review of their records, discussion with them, the care staff and observation of care practices. The Inspector spoke with all residents’ during the inspection, however some of the residents’ are unable to communicate verbally, therefore observations were made of their general well being and of their interactions with staff. Two residents’ invited the inspector to see their rooms and communal areas of the home were seen during the inspection. Prior to the inspection staff had supported residents’ in completing a pictorial questionnaire about their views of the care and services provided. These views and the views of three relatives who forwarded questionnaires have been taken into account as part of the inspection. An annual quality assurance assessment (self assessment) submitted by the manager was received and reviewed as part of the inspection process. Verbal feedback on the inspection findings was given to the Registered Manager during the inspection. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 7 As identified within the annual quality assurance assessment (self assessment) submitted by the Registered Manager there is a clear direction in the way to move forward. Advice would be to ensure that the plans for improvement are implemented and monitored. The plans indicate continued improvement and maintenance of standards of care and increased choice and independence for residents’. 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. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.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 Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process provides assurances that the needs of residents’ entering the home can be met. EVIDENCE: There is a statement of purpose and a service user guide, which provide information about the services provided. The documents include some pictures to try to aid understanding for residents’. However the Registered Manager plans to improve the accessibility of the information to residents’ over the next twelve months with their help. There is an admission process for new residents’, which includes assessing and taking account of the needs of current and prospective residents’. However no new residents’ have been admitted since the last inspection and there are no vacancies. Questionnaires received from residents’ confirm that they were asked for their views about moving into the home and that they visited before making a decision. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ are receiving a good level of support in developing their communication skills, which is improving their level of choice in their daily lives. EVIDENCE: A sample check of residents’ care records confirmed that care and support plans are in place to guide and support the care provided to them. The plans were more detailed and specific about individual residents’ needs, which help staff to provide consistent care. Staff have received training in person centred planning and discussion with a staff member and observations during the inspection confirmed that they understand residents’ individual needs. Residents’ are involved in the care planning process and a resident confirmed this during the inspection. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 11 The annual quality assurance assessment completed by the Registered Manager identifies communication as an area that has improved over the last twelve months. This was confirmed during the inspection. Different communication methods were found to be in use and effective including objects of reference, pictures and photographs. Implementation of appropriate communication methods is enabling residents’ to be more independent in making choices and decisions in their daily lives. For example the objects of reference are being used to enable a resident to choose when and whether to have a bath or shower and to request drinks and food. Since the last inspection residents’ have been supported in starting to manage their own finances. As part of this process, all residents’ now have a lockable facility and are supported by staff in keeping and managing small amounts of money. A sample check of residents’ records confirmed that relevant risk assessments are in place. There is a process where staff have to sign to confirm that they have read and any new risk assessments or changes to them, helping to reduce risk to residents’. Discussion with a resident and staff identified that while action is taken to minimise risk, residents’ are being encouraged to work towards personal goals and to be as independent as possible. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ are receiving support to develop a fulfilling lifestyle according to their individual needs and preferences. EVIDENCE: It was evident from observations through the inspection that residents’ are being supported in developing their social, emotional, communication and independent living skills. The Registered Manager advised that the Consultant Psychologist and his team have given advice about strategies for meeting the varying needs and managing behaviours, which has helped to create a calmer atmosphere for residents’. The atmosphere was much calmer than on previous inspections and residents’ were able to communicate their needs more appropriately to staff. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 13 Care plans acknowledge residents’ religious needs and identify any support that they need to meet their spiritual needs. For example attendance at church and if staff support is required. All of the residents’ attend day centres, a pictorial programme of their day activities is held on their care file. A resident spoken with on their return from day centre, discussed arrangements that were being made to support them in considering a change of day service which will provide them with further opportunities. Discussion with the Registered Manager confirmed that residents’ were supported in trying to access more appropriate day services where applicable. Review of a residents’ records, discussion with a resident and staff confirmed that residents’ are encouraged and supported to access community facilities. This includes shopping, restaurants and country parks. A resident also said that they go swimming regularly and enjoy this. Questionnaires received from residents’ say that they can choose how to spend their leisure time. Residents’ are being encouraged to develop their interests in leisure activities that they can take part in at home. For example, one resident particularly enjoys music and dancing and is supported in accessing this. Residents’ routines are relatively flexible and largely determined by their individual commitments such as attendance at day centres. Observations on their return from day centre late afternoon identified that they all have their individual routines on return and choose whether to spend time in their rooms or with other residents’ and staff. Residents’ are also gradually being encouraged to take part in the day to day tasks in the house and to be more independent with household tasks such as making drinks. Comments and responses received in questionnaires from relatives confirm that residents’ receive good support in maintaining contact with relatives and that staff support them where necessary on visits to family. A resident spoken with was happy with the meals provided. Weekly meetings are held with residents’ to agree a menu for the week. Pictures and photographs are used to help residents’ with making choices and decisions about meals. Individual preferences are taken into account and adaptations made to the menu where necessary to meet individual preferences and dietary needs. Plans for the next twelve months identified in the annual quality assurance assessment include working with staff and residents’ to develop their knowledge of healthy eating. The Registered Manager has also identified plans to involve the dietician. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ receive very good support in managing their physical and mental health. EVIDENCE: Residents’ are involved in the development of their care plans, which detail the level of support that they need to assist them with their personal care. Staff are aware of residents’ individual needs and there was evidence that residents’ are supported with individual preferences. A questionnaire from a resident stated that they are able to have a bath when they want one. Residents’ all have health action plans in place based on their individual health care needs. Records reviewed for a resident show that health care needs are monitored and health care services accessed appropriately. Advice has been sought from a range of health and care professionals including, General Practitioner, continence nurse, chiropodist and the learning disability team. Comments received from relatives include “Always looks cared for” and “looks after the health of the residents”. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 15 Records show that residents’ receive support with managing their physical and mental health needs. Staff have received a very good level of support from a consultant psychologist and his team who have visited regularly to advise on meeting the differing needs of residents’. Records show that care plans are reviewed and revised based on the professional advice given. Discussion with the Registered Manager identified that regular input from the psychology team was helping staff to develop strategies and their skills in meeting the individual needs of residents’. The Registered Manager advised that all of the residents’ have recently had their medication reviewed. A sample check of a resident’s records confirmed that this is the case. It is important for residents’ who are prescribed long term medication to have this reviewed regularly to ensure it remains appropriate. A sample check of medication held and the records confirmed that medication is well managed. Records are clear and each resident has a medication profile, which includes their picture. This is particularly important if a situation were to arise where it was necessary to use temporary staff who may not be so familiar with residents. It is also helpful for residents’ and helps to assist their understanding. Pictures of the medication are also included as an aid for residents’. At the time of the inspection none of the residents’ managed their own medication, however a risk assessment and plan were being developed with a view to supporting a resident in managing their own medication. Some advice was given about the level of detail required in the risk assessment to minimise the risk. Standard 21 was not inspected, however the Registered Manager has identified arrangements for ageing of a resident or death as areas to be improved on. This will help to ensure that in such an event residents’ needs and preferences can be fully met. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are procedures for dealing with complaints and staff are aware of their responsibilities for protecting the people in their care. EVIDENCE: The Commission for Social Care Inspection have received no complaints since the last inspection. The Registered Manager advised that no complaints have been received directly by the service. Questionnaires received from relatives confirm that they are aware of the procedure for making a complaint and those from residents’ state that they know who to talk to if they are unhappy and no how to make a complaint. The Registered Manager has identified the development of more accessible complaint formats for residents’ as an area to be improved on over the next twelve months. The annual quality assurance assessment identifies that staff have received training in safeguarding vulnerable adults and that this is a regular item on the agenda for staff meetings. Discussion with a member of staff confirmed that they are aware of their responsibilities in relation to safeguarding vulnerable residents’. They had no concerns about how residents’ were spoken to or treated and were aware of the need to monitor any changes in behaviours from residents’ who are unable to communicate verbally. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 17 A risk assessment, which identified a resident’s vulnerability in respect of making allegations, had been implemented. Advice was given to review the safeguarding issues regularly to ensure they remain appropriate and protect the resident. Residents’ now have lockable facilities in their rooms to give them more control over their money and to enable them to keep it safe. Systems have been implemented where staff check the money with residents’ and are working with them on understanding the value of money, which also helps to protect them. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean and comfortable and when the conservatory has been completed the increase in communal space will improve the living arrangements for residents’. EVIDENCE: The home looks like any large family home in the area. Communal areas consist of a small lounge and a kitchen diner. Concerns have previously been raised in inspection reports about the limited communal space and the impact this has on residents’ who have a range of different needs. Mencap have discussed plans to erect a conservatory, to increase the communal space on several occasions. At the time of the inspection, building work to install the conservatory had commenced. This additional space should improve the daily lives of residents’. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 19 The building work was all taking place outside the home and the area was fenced off, enabling residents’ to continue accessing part of the garden while maintaining their safety. Residents’ were also enjoying watching the progress of the building work. Residents’ are able to access the enclosed garden freely. There is a swing in the garden which one resident particularly enjoys. Two residents’ invited the inspector to see their rooms. One resident was particularly keen to show their room, which had been recently redecorated with new soft furnishings. The room was clean and comfortable and the resident had chosen the furnishings and colour scheme. The Registered Manager confirms in the annual quality assurance assessment a continued commitment to involving and educating residents’ about making choices about their home. All areas of the home were clean and hygienic. Staff confirmed that the flooring in the kitchen/dining room is due to be replaced when the conservatory has been completed. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ are supported by a caring and committed staff team who are receiving ongoing training to meet residents’ needs. EVIDENCE: Responses received from residents’ in the questionnaires confirm that staff treat them well, listen to them and act on what they say. Observations during the inspection confirm that staff have built good relationships with residents’. They presented as professional, caring and committed to meeting the needs of residents’. Information received in the annual quality assurance assessment identifies that currently 30 of staff have achieved a National Vocational Qualification (NVQ) at level 2 or above. One staff member is currently undertaking the NVQ, which accounts for an additional 10 . The National Minimum Standards recommend that at least 50 of the staff team hold an NVQ. The NVQ provides staff with a basic understanding of care practices and residents’ needs. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 21 Discussion with a staff member and review of the training plan confirms that there is an ongoing programme of staff training based around meeting residents’ specific needs. For example this includes makaton training, which all staff have either completed or are in the process of completing. This enables them to communicate effectively with a resident who uses makaton to communicate. Since the last inspection six staff have attended autism training providing them with a better understanding of the needs of a resident. Discussion with the Registered Manager identified that staff have also gained a better understanding of how to meet residents’ needs through the input from the psychology team. The team have worked closely with staff, advising on various strategies, which have helped them meet the needs of residents’ more effectively. In addition to the formal training, there was evidence of less formal information sharing to increase staff knowledge and awareness. An easy read version of the Mental Capacity Act 2005 was available for staff to read and sign to confirm that they had read. This helps staff to understand their responsibilities in relation to protecting residents’ rights. Two staff files were reviewed to check the adequacy of the recruitment process in safeguarding residents. References and criminal record bureau clearances are obtained before staff start work with residents’. Records of interviews show that residents’ have a key role in the recruitment process for new staff. A Resident was part of the interview panel and had helped to develop the interview questions for prospective staff. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 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 home is managed in a manner that promotes and safeguards the health, safety, welfare and rights of residents’. EVIDENCE: Since the last inspection the Manager who has been in post since August 2006, has become a Registered Manager following a successful application for registration. The term ‘Registered Manager’ is used to describe a manager who has been registered by the Commission for Social Care Inspection (CSCI) and has specific legal responsibilities under the Care Standards Act 2000 for the conduct of the care home. The registration process includes ensuring that the Manager can demonstrate that they are suitably experienced and qualified to manage the home and meet the needs of residents. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 23 The findings of the inspection confirm that the Registered Manager has worked to ensure that the shortfalls identified at the key inspection carried out in July 2006 have been addressed. There is also evidence that the Registered Manager is committed to increasing resident choice and opportunities for them to express views through a range of communication strategies. This is an area identified for continued development over the next twelve months. Observations during the inspection identified that the Registered Manager has developed good relationships with residents’ and staff and is working with staff to manage the service in the best interests of residents’. Mencap have a range of quality assurance tools, which include gathering views from relatives and residents’. Their views are then incorporated into an annual quality plan. Unannounced visits are carried out by a Service Manager to review the quality of care provided to residents. Review of one of the reports of a visit identified that the reports are detailed and indicate that issues relevant to the care and protection of residents are considered. An annual quality assurance assessment (self assessment) has been completed by the Registered Manager and forwarded to the Commission for Social Care Inspection as part of the inspection process. The assessment clearly identifies areas that the service does well and areas, which can be improved. It is very specific to the needs of the residents’ at Barth Close and focuses on helping them to make more informed choices. No health and safety concerns were identified during the inspection. Staff receive training in safe working practices such as movement and handling and fire safety. They also receive training in first aid reducing risks to residents’. The annual quality assurance assessment identifies that equipment such as the central heating boiler and electrical appliances have regular maintenance checks helping to keep the premises safe. Building work going on outside the home to build the new conservatory was appropriately cordoned off the protect residents. Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X 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 3 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 3 3 X X 3 X Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard Good Practice Recommendations Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Barth Close, 5 (Royal Mencap Society) DS0000012702.V341141.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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