Inspection on 20/08/07 for 5 Ellasdale Road

This inspection was carried out on 20th August 2007.

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

The inspector 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 Ellasdale Road 10/08/06

5 Ellasdale Road 11/01/06

5 Ellasdale Road 19/07/05

5 Ellasdale Road 09/02/05

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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 5 Ellasdale Road 5 Ellasdale Road Bognor Regis West Sussex PO21 2SG Lead Inspector Ms A Campbell-Currie Unannounced Inspection 20th August 2007 12:00 5 Ellasdale Road DS0000061616.V342846.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 5 Ellasdale Road DS0000061616.V342846.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. 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 5 Ellasdale Road Address 5 Ellasdale Road Bognor Regis West Sussex PO21 2SG 01243 865459 F/P 01243 865459 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) Sussex Autistic Community Trust (Care Services) Limited Ms Alexandra Reeve Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 2006 Brief Description of the Service: 5 Ellasdale Road is a care home, which is registered to provide personal care for up to six service users in the category learning disability (LD) who are between the ages of 18 to 65 years of age. The service has been set up to provide care and accommodation for younger adults with autistic spectrum disorders. It is a semi- detached property, which has been extended and adapted for its current use, and is located in the town of Bognor Regis. The property is a three storey building providing private accommodation to service users in six single bedrooms located on the first and second floors. Communal accommodation is made up of two lounges and a dining room located on the ground floor. An enclosed garden, which is available to service users, is located to the rear of the premises. Fee levels currently range from £69,790 to £103,797 per annum. The registered provider of this service is Sussex Autistic Community Trust (SACT). The Responsible Individual acting on behalf of the organisation is Mrs Jean Rose. Ms Alex Reeve is the registered manager and is responsible for the day to day running of the care home. 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Unannounced Inspection included a site visit that was carried out over three and a half hours. Judgements have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service, as well as evidence gathered from a range of sources since the last inspection of the home. The manager completed an Annual Quality Assurance Assessment (AQAA) that included a great deal of valuable information about the home and developments that will further improve the quality of life for people living there. Relevant documents and samples of case records were read. Surveys were sent to six relatives who are all involved in the care of their adult son or daughter. Five people returned them and provided useful information about their experience of the home. Due to the communication difficulties of people living at 5 Ellasdale Road they were unable to complete surveys however staff explained the inspection to them on a one-to-one basis. There were two people receiving care in the home, two people at a resource centre, one person was on an adventure holiday and another was celebrating his birthday with his family. Time was spent with the manager, the deputy manager and the member of staff who was on duty. A tour of the building and garden was also carried out to see the facilities that are available to people. The assessment of the service included considering the outcome for service users in relation to the key National Minimum Standards for Younger Adults. What the service does well: The home is a safe and comfortable place for people with autistic spectrum disorders. The atmosphere is calm and homely. There are notices in symbol format and photographs to help people understand their environment. People have made their rooms the way that they like them to reflect their personality and interests. There is a thorough recruitment process to make sure people are protected from harm. People living in the home have a chance to meet prospective care staff before they are appointed. Staff are well trained and supported to do their jobs and are committed to providing a good quality of life for people. Care plans are detailed and advice from everyone who knows each person has been included. The care and daily activity programme is carefully planned around the goals and wishes of each person to make sure they get all the help they need to increase their independence. 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. All service users have their individual needs and aspirations assessed before a decision is made about them moving to the home. People can be sure that the home will meet their needs and aspirations. EVIDENCE: The six people living at 5 Ellasdale Road moved into the home when it opened in 2004. All service users had moved from residential schools or other care homes. The case records of three service users were read and showed that detailed assessments had been carried out before people moved. Information had been gathered from parents, service users themselves where possible and other professionals who were involved with their care. The assessments were detailed and covered all aspects of the person’s needs so that clear care plans could be drawn up. There is a new format for carrying out assessments that is more holistic and includes more detail about peoples social, emotional and spiritual needs. The manager is working with a member of staff within the Sussex Autistic Community Trust (SACT) who coordinates the Training and Education of Autistic and related Communication for Children (and adults) who are 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 9 Handicapped (TEACCH). This system is used in the home to help staff communicate more effectively with service users. They are working on an application pack that will be easier for people with autistic spectrum disorders to understand. The staff spoken with said that they are given the information and knowledge they need to provide for the care needs of the people who live in the home. Feedback from parents who returned surveys also indicated that this is the case. 5 Ellasdale Road DS0000061616.V342846.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 and 9 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People have their individual needs and personal goals detailed in their care plans that are kept under review. People are supported to make decisions about their lives and are supported to take risks as part of an independent lifestyle. EVIDENCE: The format for care planning that is used in the home is specifically designed to identify the needs, goals and aspirations of people with autistic spectrum disorders. Samples of individual care plans were read and it was clear that they had been drawn up using information gathered from a range of sources including parents and health and social care professionals. Each care plan begins with a pen picture of the service user with some key areas of specific need, preferences and risks identified. 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 11 The care plans are very detailed with clear guidance to staff. All aspects of the person’s needs and wishes are noted including spiritual or cultural needs and goals. Significant personal and family events were also noted. Assessments of people’s independent living skills had been carried out with detailed guidance in aspects of daily life where support from staff is needed; for example assisting with meal preparation. Another person is being supported with handling and understanding money so that he can now be more independent when shopping. A member of staff was supporting a service user at home and the guidelines in his care plan were being followed. There was evidence that each service user has an annual review that involves health and social care professionals and parents where appropriate. Care plans are also kept under review through the year. Communication needs are noted and all staff have skills in using Makaton signing that three service users understand. People had been involved in identifying their own goals where possible although due to the communication needs of the people living in the home they depend on others to make decisions in their best interests. Everyone living in the home has support from parents and there is an independent advocacy service available. There were daily plans that detailed the person’s goals for each day. The care plans seen detailed the way that staff can support individuals to make choices in their lives; there was visual evidence of this around the house with photographs and guidance in symbol format to help people understand their surroundings. Comments received from parents of five service users indicated that their adult son or daughter is receiving the care that they need and two people said that people’s choices are always taken into account. Risk assessments had been carried out in all aspects of the person’s life. The manager said that a behavioural consultant has provided advice and guidance about supporting people to manage risk and increase their independence. Staff from the Community Learning Disability Team are very supportive and provide assessments and guidance. There are guidelines for managing behaviour and minimising risks where this had been identified. Risk assessments had been kept under regular review. 5 Ellasdale Road DS0000061616.V342846.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): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People take part in activities that they enjoy and help them develop their skills. People are encouraged and supported to take part in local community activities. People are supported to maintain contact with family and friends and to develop new friendships. People’s rights are respected and responsibilities recognised in their daily lives. People are offered a healthy diet and enjoy their meals and mealtimes. EVIDENCE: The assessments, care plans and daily timetables showed that people’s individual interests, goals and needs had been taken into account in planning activities that people wish to take part in. Five people attend a local resource centre, which is within walking distance. The centre was set up by the provider and has a manager and small staff team; the care staff from the home attend alongside service users so that there is a consistent approach. A 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 13 variety of activities are available including: arts and crafts, cooking and money management. One person has an individual programme from home, as the resource centre did not meet his needs. Three people also attend college and educational based activities. One person is being supported with money management and is due to attend a local structured programme with a view to future employment. The home is near the town centre, the beach and local shops. The manager said that people are encouraged to be involved in local community activities. One person has had travel training with a voluntary organisation so that he will be able to access the community safely; another service user has been assessed as able to go out with one member of staff rather than two, which shows progress with the support he has received from staff. One person has a trip to the theatre once a month; others attend the gym. One of the service users is a talented artist with work displayed at a local gallery; she has a ‘buddy’ from the gallery who supports her with her artwork. Everyone has had a holiday abroad this year with support from staff. It was clear from case records and feedback from surveys that people are supported in their contact with family and friends. One person was at home celebrating his birthday with his family. Relatives who returned surveys said that they are made to feel welcome when they visit and one person said staff support them during their visits. There is a policy regarding supporting people in establishing friendships and intimate relationships. People’s needs and wishes regarding sexuality are noted on assessments and care plans. The manager said that the community nurse from the Learning Disability Service has provided advice and guidance on sexuality issues. Everything is done to promote people’s rights and privacy is respected within a risk assessment framework. All bedroom doors are lockable; one person has a key to his room, which he is able to use with prompting from staff. People can spend time in the privacy of their rooms; two people have the use of two summerhouses in the garden if they want quiet time away from the other people in the home. The manager said that the time people spend on their own is monitored to ensure that people do not become isolated. There is a varied and balanced menu and people are involved in the meal planning and preparation. Evidence of this was seen on case files with risk assessments to ensure people have the level of support in the kitchen that they need. There is an emphasis on healthy eating and people are encouraged to take exercise daily. Two people take their meals separately in a quieter atmosphere that suits them. 5 Ellasdale Road DS0000061616.V342846.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive personal support in the way they prefer and their physical and emotional health needs are met. People are supported to retain and administer their own medication subject to a risk assessment. The home’s policies and procedures regarding medication protect service users. EVIDENCE: There are policies regarding the way that people should be assisted with their personal care. The induction programme includes detailed guidance to staff about providing personal care for people with autistic spectrum disorders. Each person has a very structured timetable for their morning and evening routines; these are recorded in their individual care plans which include detailed guidance for staff about the way people like and need support. The staff spoken with said they are clear about how to provide personal support. Two people have been supported to become more independent with their personal care and now need minimal support. Staff were observed to be providing care in a sensitive and respectful manner. 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 15 The case records showed that people have the health care that they need. Each person has a Health Action Plan, which is in a user-friendly format. The GPs and Community Nurses have been involved in this process. Action points from the plan are being achieved with support from key workers. One person is able to understand his health issues and it is planned that staff will help him to have access to better health information. ‘Best Interest’ Meetings are set up with the GP and input from the psychiatrist to ensure that people receive the health care input that they need. People’s ability to give informed consent to their care is an issue that is relevant to the provision of their healthcare. It was clear from case records that people receive support from a number of health care professionals including occupational therapists, speech and language therapists and mental health professions. The manager said that the home has a good relationship with staff in the local Community Learning Disability Team. All staff have read and signed the organisation’s medication policy. There is also guidance specific to the needs of people in the home. All staff have received training on the safe administration of medication and competency tests have been carried out; the outcomes are on staff files. One person is self-medicating with support and risk assessments have been carried out. Medication is stored in lockable facilities in people’s rooms and there is clear guidance for staff about administration. The recording system was seen to be in order. 5 Ellasdale Road DS0000061616.V342846.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can feel that their views are listened to and acted on. People are protected from abuse, neglect and self-harm. EVIDENCE: There is a complaints policy and system for recording complaints; none have been recorded in the past twelve months. The manager said that she encourages an open approach to concerns and complaints so that they could be addressed as soon as possible. Due to communication difficulties staff work on a one-to-one basis with service users to assist them to express their views and concerns. Staff use Makaton signing with three people who are able to respond to this form of communication. Partnership days are held once a year and on the last occasion the parents of five service users were able to attend. This is a forum for exchanging information and concerns. People indicated on surveys that they find these days very helpful. Relatives who returned surveys indicated that they feel their concerns are addressed quickly and efficiently. The manager said that she has received letters and emails with positive feedback about the care provided at the home. There are policies and procedures regarding adult protection. All staff attend training on safeguarding vulnerable adults as part of their induction. The staff 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 17 spoken with were all clear about how to keep people safe and the need to report any concerns immediately. There is a policy about dealing with challenging or aggressive behaviour; a behavioural consultant from the organisation is available for advice if necessary 5 Ellasdale Road DS0000061616.V342846.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with a comfortable and safe home that is clean and hygienic. EVIDENCE: The home was clean and well maintained. The garden is enclosed with two summerhouses for people to use; one has been purchased by one of the service users for his own use. The communal areas are comfortable and there is some sensory equipment in one quiet lounge to help people feel relaxed. Maintenance records are kept and there are bi-monthly meetings with the housing association that owns the building in order to deal with any maintenance issues. Monthly audits take place and the deputy manager has delegated responsibility for health and safety in the building. The home meets the requirements of the fire service. Hot water levels are restricted as 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 19 required to keep service users safe from the risk of scalding. The manager said that there is an ongoing problem with the boiler that is being taken up with the housing association. Three bedrooms were seen and clearly reflected people’s personal preferences and interests. The care staff, in particular the waking night staff are responsible for cleaning duties. The carpets in communal walkways were stained; the manager said that these have been cleaned recently. New flooring is being ordered to make sure these areas of the home can always be kept clean and hygienic. The laundry facilities are suitable for the home. Service users are supported to do their own laundry and to carry out cleaning duties in the home within their abilities. Alcohol gel dispensers have been provided in the kitchen to minimise the risk of infection and cross contamination. 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by competent and qualified staff and an effective staff team. The home’s recruitment policy protects the welfare of service users. Individual and join needs are met by very well trained staff who are well supported and supervised. EVIDENCE: There are nine full time and one part time members of staff in the team. The staffing rota was seen and showed that there are four staff on duty in the morning, three in the afternoon and one waking and one sleeping member of staff at night. Service users also have input from staff at the resource centre during the day. There are sufficient numbers of staff on duty to meet the needs of people living there. The staff are trained in providing for the specific needs of people with autistic spectrum disorders and all are able to use Makaton signing so that they can communicate more effectively with three of the service users. There are 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 21 regular staff meetings and staff said that the handover of information between shifts is always clear to make sure people know of any progress, incidents or changes that have occurred during the day. Five full time and two part time staff have left in the past year to pursue their careers; this has meant that relief staff and managers have covered regular shifts. There has been a recruitment drive and new staff have been appointed. One relative who returned a survey said that the period of change had been managed well. There is a robust recruitment policy and process that is provided by the organisation. Samples of staff recruitment records were seen. These showed that all the necessary checks including Criminal Records Bureau (CRB) checks had been carried out before staff began in work to make sure that people living in the home are protected. An equal opportunities approach is taken to recruitment and records of interviews to show this were seen on staff files. The manager emphasised the importance of recruiting staff who have an understanding of the issues for people who have autism. Prospective staff are invited to the home for the second interview so that service users can meet them and be involved in the process. There is a comprehensive induction and training programme. The induction programme meets the standards of the Skills for Care Council. Staff said that they have at least seven paid days for training each year and that they are supported and encouraged to attend any training that will be useful in their work. There is a programme to support staff to achieve the National Vocational Qualification (NVQ) in care. Four people have the NVQ level two or above; two people are working towards this award and the deputy manager is working towards the NVQ level four award. Staff have attended all the mandatory training to ensure that they understand how to protect the health and safety of people living in the home. A relative commented that the staff are well trained and professional. There is an annual appraisal process and a system to ensure that staff receive regular supervision with their line manager. There was evidence to show that people have regular supervision and staff spoken with confirmed that this is the case. Staff who provide supervision have all attended training on supervision skills. 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from a very well run home and they can be confident that their views are taken into account in the development of the service. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: Ms Alex Reeves is the registered manager of the home; she has nine years of experience of managing care homes and is a specialist in providing care for people with autistic spectrum disorders. Ms Reeves attends management training run by the organisation and other relevant training sessions in order to update her knowledge and skills. 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 23 Representatives from the organisation carry out monthly audit visits to make sure the manager and staff are maintaining and developing the service for people living there. It is clear from feedback from relatives and staff and observation of people in the home that the manager has established an open and inclusive atmosphere for people living and working in the home. Every effort is made to support service users to improve their communication skills and express their views; this is done through one-to-one work, structured programmes and the use of photographs. Partnership days were set up to ensure that relatives feel fully involved in the care of their adult son or daughter. Before each meeting questionnaires are circulated so that people could raise any issues; this process helps the manager to plan the agenda for the day. Feedback from the relatives who returned surveys indicated that this process is very useful and that issues are addressed promptly. The meetings are held on Sundays so that working people can attend and there is a social event in the home following the meeting. The measures to ensure the health and safety of service users is protected are in place. Hazardous materials are kept locked when not in use. Equipment is services as required and the home meets the requirements of the fire service. All staff have attended health and safety and fire training. There is an evacuation procedure in the event of fire and all staff are familiar with this. There is a system for recording incidents or accidents and the Commission is kept informed as required. 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 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 3 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 X 3 X X 3 X 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 25 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 5 Ellasdale Road DS0000061616.V342846.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 5 Ellasdale Road DS0000061616.V342846.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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