Inspection on 26/03/07 for 51 Norton Road

This inspection was carried out on 26th March 2007.

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

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

Other inspections for this house

51 Norton Road 04/03/09

51 Norton Road 03/01/06

51 Norton Road 28/09/05

51 Norton Road 07/03/05

51 Norton Road 18/01/05

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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 51 Norton Road Hove East Sussex BN3 3BF Lead Inspector Lucy Green Key Unannounced Inspection 26th March 2007 10:15 51 Norton Road DS0000014148.V323367.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 51 Norton Road DS0000014148.V323367.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. 51 Norton Road DS0000014148.V323367.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 51 Norton Road Address Hove East Sussex BN3 3BF 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) 01273 747449 01273 747449 ftf1d@tiscali.co.uk The Frances Taylor Foundation Vacant Care Home 10 Category(ies) of Learning disability (10) registration, with number of places 51 Norton Road DS0000014148.V323367.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is ten (10). Service users must be aged between eighteen (18) and sixty-five (65) years on admission. Service users with a learning disability only to be accommodated. Date of last inspection 3rd January 2006 Brief Description of the Service: 51 Norton Road is registered to provide residential care to ten adults with learning disabilities. The home is located in Hove with good access to local transport and amenities and Brighton town centre is within fifteen minutes walking distance. Resident accommodation is provided on four floors, each with en-suite toilet and washbasin facilities. All bedrooms are decorated and furnished to reflect individual tastes and interests. The communal areas consist of a quiet lounge, large lounge/dining room, and separate kitchen. There is an attractive garden and patio area to the rear of the home. The Frances Taylor Foundation is the Registered Provider of the service. Information received from the Manager on 20 December 2006 details that the current baseline cost of placement at 51 Norton Road is £705 per week. More detailed information about the services provided at 51 Norton Road can be found in the home’s Statement of Purpose and Service User Guide – copies of these documents can be obtained, along with the CSCI inspection reports on request from the home. 51 Norton Road DS0000014148.V323367.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at 51 Norton Road have requested to be referred to as ‘residents’. This report reflects a key inspection based on the collation of information received since the last inspection, feedback from representatives and an unannounced site visit which lasted for five hours on Monday 26 March 2007 between the hours of 10:15am and 3:15pm. The site visit included a discussion with all parties, a tour of the premises and an examination of medication, care and staffing records. There were ten residents living at 51 Norton Road at the time of this inspection visit. The home therefore has no vacancies at the current time. During the visit, the Inspector met with six of the ten residents and had private conversations with five of them. Four residents were attending external activities at the time of the visit and were therefore not seen as part of this inspection. The Inspector spoke individually with the Manager and two support workers. Two other staff were also spoken with during the inspection process. Prior to the inspection surveys were sent and returned from each resident. Following the inspection, comment cards were also sent to relatives and visitors, although none had been returned at the time of this report. What the service does well: The residents at 51 Norton Road benefit from being supported by a team of staff that clearly enjoy their work and who are dedicated to meeting the needs of the people they support. It was pleasing to observe the positive relationship between staff and residents on the day of inspection. The atmosphere at the home is one that is relaxed and friendly. When asked how life was at the home, one resident replied “I love it here so much”. Similarly, one staff member described coming to work as “being an extension of my family – with professional boundaries in place”. Staff recognise that choice is integral to the provision of good care and choice and resident control is something that is automatic at 51 Norton Road. Each resident has a key to the front door and residents are supported to be as independent as possible within a risk assessed framework. Residents’ meetings are held every week and at this time menus for the following week are discussed and chosen. 51 Norton Road DS0000014148.V323367.R01.S.doc Version 5.2 Page 6 Residents have access to a wide range of activities which meet both their social, cultural and spiritual needs. On the day of inspection, four residents were attending a day centre, one resident spent the morning horse riding and the other five residents were doing in-house activities that they had chosen. Staff have access a raft of mandatory and specialist training, with more than 50 of the staff team holding a National Vocational Qualification at Level 2 or above. 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. 51 Norton Road DS0000014148.V323367.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 51 Norton Road DS0000014148.V323367.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&4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents benefit from an admission process that ensures their individual needs and aspirations are properly assessed prior to moving into the home. The opportunity for prospective residents to visit and ‘test drive’ the home before moving provides the time for compatibility with other residents to be appropriately explored. EVIDENCE: One new resident has moved into 51 Norton Road since the last inspection. The Inspector examined the assessment information for this person. There was documentary evidence that a thorough assessment process had been undertaken prior to this person coming to live at the home. Information had been gathered from a variety of sources including obtaining a copy of the individual’s latest social care assessment. Staff spoken with confirmed that the resident had visited the home on several occasions, including overnight stays to meet with the other residents and staff and ensure the home meets their expectations. A record of these visits was in place and therefore it was possible to track the number and success of these 51 Norton Road DS0000014148.V323367.R01.S.doc Version 5.2 Page 9 visits. The resident herself also commented in the resident survey: “My mum and I came to visit several times for tea. I liked it and made friends. Then I stayed a few weekends before I moved in for good.” A placement review was held following the first six weeks to evaluate the transition to the home, which was recorded as having been successful. The resident has now been living at the home for nearly one year and all people spoken with during the inspection stated that this individual had settled in well. 51 Norton Road DS0000014148.V323367.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 benefit from a care planning system that both enables and protects them. Residents are fully involved in all decisions that affect their lives. EVIDENCE: Staff practices observed throughout the inspection demonstrated a good understanding of the residents and their needs. The interaction between staff and residents was positive and the atmosphere at 51 Norton Road was found to be relaxed, friendly and happy. Care and support was seen to be provided in a sensitive, dignified and respectful way. The support guidelines in the three care plans viewed, reflected the needs and wishes identified by the residents themselves. 51 Norton Road DS0000014148.V323367.R01.S.doc Version 5.2 Page 11 Care plans contain detailed information about how care should be delivered and the emphasis of the care planning system is to retain and where possible, develop independence. There was documentary evidence that care plans are regularly reviewed, with a formal review of care needs every six months. The Manager reported that care plans are reviewed on a monthly basis for those residents who are now over sixty-five years of age. One resident informed the Inspector that her mobility needs had changed since having a fall and that she now uses a wheelchair outside the home at all times. On examination of this person’s care plan it was evident that this information had been documented, but the care plan in place for mobility still referred to the resident using her rollator for trips out. Whilst it was apparent that all staff were aware of the correct guidance, it is a requirement that the Manager ensure that this information is made more explicit in the relevant section of the care plan. Discussion with the two staff interviewed, highlighted that staff had a good understanding about residents’ longer term aspirations and they provided examples of how they support residents to plan for the future. One staff member stated; “life does not end at 51 Norton Road” and went on to explain how the home has supported a number of residents to move out into the community. The information in care plans however, is not entirely reflective of the home’s practical approach to supporting residents to set and achieve goals. It is therefore required that the Manager implement a formal system for recording the hard work that is actually going on in respect of goal and life planning. Care plans contain a range of risk assessments for each resident with a clear objective that risk assessments should be enabling rather than restrictive. The documentation in place for one resident outlines the safety measures in place to enable this individual to manage her own medication and access the community independently. It was again evident that residents continue to have much control over their lives and the way they spend their time. All residents spoken with confirmed that they are able to get up, go to bed and have their meals at times which suit them. Five residents showed the Inspector their bedrooms and all stated that they had chosen the décor and furniture in their rooms. During the inspection residents were observed making decisions and being consulted with by staff. One resident informed the Inspector that a residents’ meeting is held every Thursday, during which the menu plan for the next week is discussed and chosen. 51 Norton Road DS0000014148.V323367.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. Residents are supported to lead healthy and fulfilling lives. Residents benefit from a range of nutritious and well-balanced meals. EVIDENCE: The residents at 51 Norton Road are supported to lead their lives as they choose. The activity timetable on display was found to reflective of the type of activities that the residents spoken with said they enjoy. Throughout the inspection, it was also highlighted that staff are sensitive to the differing needs and energy levels of residents. Evidence gathered from the activity timetable, care plans, discussions with residents and staff revealed that residents access a range of external courses and day services. At the time of the inspection, four residents were out at day 51 Norton Road DS0000014148.V323367.R01.S.doc Version 5.2 Page 13 centres and one was horse riding in the morning. The home also runs three internal activity groups, which include photography, art and knitting. Both residents and staff reported that the in-house activity sessions were well attended and thoroughly enjoyed. The residents are encouraged to be involved in the running of the home and consequently time is built into their schedules for undertaking household tasks. One resident spoken with confirmed that she takes great pride in doing her own laundry and another stated that she especially enjoys making her own sandwiches at the weekend. During the inspection, one resident assisted staff with the food shopping and on their return other residents were engaged in helping to unload the car and put the food away. Each resident has their own key to the home, which also operates the lock to their bedroom door. During the inspection, it was evident that residents have the freedom to live their lives as they choose, whilst understanding the responsibility of living with other people. Discussion with one resident, revealed that she prefers to spend a lot of her time watching sport on the television, rather than going out. The activity plan for this individual was reflective of this wish, but also incorporated those outings and external activities that she does enjoy, including going to watch cricket matches and dog racing. This resident also indicated that she would like to have digital television so that she could have more channels and watch films and more live sport. Following a conversation with the Manager, it was agreed that this request could be facilitated. Several residents access a range of evening activities, including attending a variety of social clubs. One resident goes to church every Sunday independently and another resident confirmed that she is supported to go when she requests to. Staffing levels are flexible according to activity programmes, although one resident and one staff member did raise the issue that there is sometimes a shortage of drivers which can impact on how people go out. On discussion with the Manager, there was evidence that there are six staff who can drive the vehicle, but it is recommended that she review the rota to ensure there are sufficient drivers on each shift. 51 Norton Road has a positive approach to enabling residents to maintain contact and relationships with families and friends. There was evidence in the care plans that the home supports residents to meet with and receive visits from their families. One resident informed the Inspector that staff take her to visit her mum each week. Another resident talked to the Inspector about a friend who she visits regularly and sometimes stays overnight with. A review of this individual’s care plan provided evidence that the home had undertaken an appropriate risk assessment in respect of this activity. Similarly, resident’s reviews include the opportunity for residents’ relatives/representatives to attend if the resident wishes. 51 Norton Road DS0000014148.V323367.R01.S.doc Version 5.2 Page 14 Meals at 51 Norton Road are discussed at weekly residents’ meetings and consequently a menu is drawn up in consultation with residents and reflects the meals they wish to have. The menu displayed showed a range of varied and well-balanced meals. The Inspector spoke with five residents individually and all reported that they liked the food prepared and that their favourite meals were included on the menu. One resident commented that “the food is really nice and you get a choice”. Two residents have drink and snack making facilities in their bedrooms and they stated that they really enjoyed the freedom and independence that this allows. On the day of inspection, the Inspector observed the serving of the lunchtime meal. The meal of soup, bread and fresh fruit was appetising and wellpresented. Staff were seen to be eating with the residents in the dining room and the mealtime was observed to be a relaxed and friendly occasion. 51 Norton Road DS0000014148.V323367.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the provision of flexible and respectful personal and healthcare support and are protected by the systems in place to manage medication. EVIDENCE: Residents are encouraged and supported to manage their own personal care as far as possible. The role of staff in supporting most residents is primarily to prompt them as necessary and for some, ensure they are safe in accessing the bath. There was evidence in the care plans and through staff discussion that support is offered in a sensitive and respectful manner. Staff were observed supporting residents in a respectful and flexible way at the time of the inspection. Staff support residents to ensure their health needs are met. The Manager reported that each resident has a health action plan, in line with the recommendations from the Valuing People paper (2001). Residents have total 51 Norton Road DS0000014148.V323367.R01.S.doc Version 5.2 Page 16 ownership of the health action plans and these are kept in locked cupboards in residents’ bedrooms. One resident showed the Inspector her plan. Care plans also contain a record of any visits or contact with healthcare professionals, along with details of the support that staff need to provide to residents to keep them healthy. The storage and administration of medication were found to be generally satisfactory. Records for most medicines were accurate and current. It was however highlighted to the Manager that there needed to be a more robust audit trail in respect of non-oral medication as medicines, such as topical creams were not routinely being signed for. Staff spoken with confirmed that they receive appropriate training in the management of medication. Two residents administer their own medication and appropriate risk assessments for this activity are in place. One of the residents showed the Inspector the locked cabinet in their bedroom where the medication is kept. The medication policy was not inspected on this occasion. 51 Norton Road DS0000014148.V323367.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and visitors to the home benefit from and are protected by, the open culture at 51 Norton Road where they know their views will be listened to and acted on. EVIDENCE: The home has a complaints procedure in place and a pictorial format has been produced for residents. These documents were not inspected on this occasion, although residents expressed that they knew how to air their views. The Manager stated in information submitted both before and during the inspection, that the home has not received any complaints about the service in the last twelve months. The CSCI has not received any complaints about 51 Norton Road since the last inspection. The home seeks to operate an open culture where issues are openly discussed and opinions shared. Positive interaction was observed between residents and staff during the inspection. Residents’ meetings are held every Thursday. Various systems are in place to protect residents from abuse. The two recruitment files inspected showed that new staff are employed subject to robust checks. The two staff members spoken with confirmed that they had attended training in the protection of vulnerable adults and that they were clear of their responsibilities in this area. 51 Norton Road DS0000014148.V323367.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 good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a homely, safe and clean environment that meets their needs. EVIDENCE: Five residents participated in the Inspector’s tour of their home and proudly showed their bedrooms. The home was found to be clean, tidy and wellmaintained throughout. Accommodation at 51 Norton Road is across four floors with level access being provided by way of a passenger lift. The provision of communal space includes a quiet lounge with drink making facilities, a large lounge/dining room and separate kitchen. 51 Norton Road DS0000014148.V323367.R01.S.doc Version 5.2 Page 19 Resident accommodation is provided in ten single bedrooms each with en-suite toilet and washbasin facilities. Bedrooms have been decorated and furnished to reflect individual tastes and preferences. Assisted bathroom and toilet facilities are provided throughout the home. The external grounds offer enclosed patio areas. 51 Norton Road DS0000014148.V323367.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, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a dedicated and competent team of staff and are protected by the robust recruitment procedures. Staff have both the skills and support to enable them to perform their roles effectively. EVIDENCE: Discussion with two staff members identified that staff hours are applied flexibly, but with a minimum of three staff during the morning and two staff in the afternoon. The Manager, cleaner and maintenance person are supernumerary to these figures. At night, the home is covered by one waking night duty. The rota was found to be reflective of these levels. The atmosphere in the home was observed to be calm and relaxed on the day of the inspection and there were sufficient staff on duty to meet the needs of the residents. During the day, five residents were out on external activities and therefore the staffing ration was 3-5 in the morning and 2-5 in the 51 Norton Road DS0000014148.V323367.R01.S.doc Version 5.2 Page 21 afternoon. Staff spoken with said that whilst they were often busy, these levels were generally adequate to meet the current needs of residents. The recruitment files for two new staff members were viewed and found to contain the required information, thus demonstrating a robust system of recruitment. There was documentary evidence that new members work towards completion of approved induction and foundation programmes. The training audit was viewed and it was evident that staff have access to a range of specialist and mandatory training. Staff spoken with said that they felt they had the necessary skills and experience to do their jobs and that they felt well supported. One staff member commented “I really like working here…good client group, good staff team and brilliant management”. All residents spoke highly of staff, with comments such as “staff are kind to me” and “staff are good and they let me be independent”. In information submitted to the Commission on 20 December 2006 as part of the inspection process, the Manager stated that 50 of staff members have completed National Vocational Qualifications (NVQ). At the time of the inspection, the Manager confirmed that with the exception of just two staff, all staff at 51 Norton Road had either completed or were enrolled on NVQ training. 51 Norton Road DS0000014148.V323367.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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a safe and well run home that has effective systems in place to self-audit and improve. EVIDENCE: Since the last inspection, the Registered Manager left and the previous Deputy Manager has become the Manager of 51 Norton Road. Whilst, the Manager is not yet registered, the CSCI has received an application which is currently being processed. All staff spoken with were extremely complimentary about the management of the home. One staff member told the Inspector “I feel well supported by the 51 Norton Road DS0000014148.V323367.R01.S.doc Version 5.2 Page 23 Manager and home is very up to date and always planning for the future”. Another staff member commented: “brilliant management”. Residents were equally complimentary about the way the home is run. The Frances Taylor Foundation has implemented a number of systems for monitoring quality assurance and there a number of checks by the organisation to ensure that the home is performing. Monthly monitoring visits are carried out on behalf of the Registered Provider and copies of these reports were viewed during the inspection. In addition to these, the Manager is required to audit the home against a tool that is based on the National Minimum Standards. The Quality Assurance Manager then assesses the home against this tool which generates a list of improvements for the home to action. The home has a number of systems in place to gain feedback from residents and these were evidenced by way of weekly residents’ meetings. Annual feedback questionnaires are also sent out to residents and staff. The results of these were positive with comments from relatives including; “the staff are very caring and professional” and “I always come back home satisfied in the knowledge that my daughter is well looked after”. In information submitted to the CSCI by the Manager on 20 December 2006, it was evident that 51 Norton Road has various systems in place to ensure the Health and Safety of the home are maintained. The Manager also reported that staff now receive fire training on a sixth-monthly basis in line with their newly updated fire risk assessment. The records in respect of health and safety were therefore not inspected on this occasion. 51 Norton Road DS0000014148.V323367.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 4 3 X 4 4 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 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X 51 Norton Road DS0000014148.V323367.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement The Registered Person must ensure that the mobility care plan for the service user discussed is updated. The Registered Person must ensure that there is a formal process of setting and monitoring goals that is linked to service users’ long term aims and aspirations. The Registered Person must ensure that there is a clear audit trail for the dispensing and administration of all medicines, including creams. Timescale for action 01/05/07 2. YA6 15(2) 01/07/07 3. YA20 13(2) 01/04/07 51 Norton Road DS0000014148.V323367.R01.S.doc Version 5.2 Page 26 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 YA13 Good Practice Recommendations The Registered Person is recommended to conduct a review of the number of drivers on each shift to ensure that all external activities can be accessed. 51 Norton Road DS0000014148.V323367.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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. 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