Inspection on 29/08/07 for 52 Wellington Road

This inspection was carried out on 29th 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

52 Wellington Road 30/11/06

52 Wellington Road 19/12/05

52 Wellington Road 14/06/05

52 Wellington Road 17/03/05

52 Wellington Road 17/03/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 52 Wellington Road Taunton Somerset TA1 5AP Lead Inspector Jane Poole Unannounced Inspection 29th August 2007 09:15 52 Wellington Road DS0000039964.V344484.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 52 Wellington Road DS0000039964.V344484.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. 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 52 Wellington Road Address Taunton Somerset TA1 5AP 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) 01823 334132 01823 327560 Home First & Foremost Ltd Care Home 12 Category(ies) of Learning disability (12), Physical disability (12) registration, with number of places 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for 12 persons in categories LD and PD Date of last inspection 30th November 2006 Brief Description of the Service: 52 Wellington Road is registered with the Commission for Social Care Inspection to provide care for up to 12 people in the categories of LD (learning disability) and PD (physical disability). The home is a large older style house situated within walking distance of Taunton town centre and many other local facilities. All service users rooms are for single occupancy and there are a variety of communal areas. Milbury Care / Voyage South Limited owns the home. The current scale of charges is £865.00 to £1663.00 per week. 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by 1 inspector over a period of 7.5 hours. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. The inspector was able to meet with staff and people living at the home, tour the building and view records. At the time of the inspection there were ten people living at the home, one person was away staying with family. Many of the people living at the home are unable to fully express their views. The inspector was able to eat lunch with some service users and to observe care practices. The manager was not at the home during the inspection but the deputy was available throughout the day and the area manager was at the home for part of the morning. The inspector was able to speak with the manager by phone the day after the inspection. Two service users, five relatives/carers, one healthcare professional and eight members of staff completed questionnaires prior to the inspection and some of the comments from these have been included in this report. What the service does well: 52, Wellington Road accommodates service users who have learning difficulties and many have complex needs relating to behaviour and communication. There is a warm relaxed atmosphere in the home with staff interacting with service users in a respectful but friendly manner. All staff spoken to were very well motivated and demonstrated an obvious commitment to providing a high quality service. The inspector saw evidence that all prospective service users are assessed by the manager to ensure that the home will be able to meet their needs. Prospective service users and their representatives have opportunities to visit the home before making a decision to move in. Care plans seen were comprehensive and staff stated that they provided clear information and guidelines to assist them to support the people living at the home. 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 6 The inspector observed that there was good interaction between staff and service users but also noted that service users are able to spend time quietly in their rooms if they choose to. Service users are encouraged to take part in household chores in line with their abilities and wishes. In addition to assisting with the running of the home there is a wide range of leisure and social activities for people to participate in. These include going shopping, swimming, arts and crafts, bowling, nights out and horse riding. There is ample communal space in the home including pleasant outside areas. What has improved since the last inspection? What they could do better: No requirements have been made as a result of this inspection but four recommendations for good practice have been made. Although staff have undertaken training since the last inspection many felt that they did not have opportunities for training appropriate to their roles in the home. Many staff felt that they would benefit from further training in communication and senior staff felt that they should be able to access additional NVQ training in line with their level of responsibility. The inspectors viewed the Medication Administration Records and noted that many hand written entries had not been signed and witnessed in line with good practice guidelines. Protocols in care plans for the use of PRN ‘as required’ 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 7 medication were not dated and it was therefore impossible to evidence whether or not they were up to date or if they had been reviewed. 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. 52 Wellington Road DS0000039964.V344484.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 52 Wellington Road DS0000039964.V344484.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 & 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All prospective service users are assessed before being offered a place at the home to ensure that it will be able to meet their needs. Prospective service users and their representatives are able to visit 52, Wellington Road before deciding to make it their home. EVIDENCE: The home has a statement of purpose, which is regularly up dated and reflects the services and facilities offered. Each person has a personal copy of the service user guide which has been written in clear language and uses pictures to make it accessible to service users. This document clearly states what is included in the basic fee. The inspector saw evidence that the newest service user had had their needs assessed and had been able to visit the home prior to deciding to make it their home. The person had been able to choose which room they wished to occupy. There was also evidence that family members had been able view the home and meet with the manager before the admission. 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 10 All staff had received a days training with regard to the prospective service users individual needs. Staff stated that they found this interesting and informative. The deputy manager explained that not all prospective service users visit the home before moving in. This is dependant on individual need and ability. However the manager sees and assesses people and takes pictures and other relevant information when meeting people who may like to move into 52 Wellington Road. Two service users completed questionnaires prior to the inspection both answered YES to the question “ Were you asked if you wanted to move into the home?” 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are well written and give clear information about peoples abilities and needs. Service users are encouraged to make choices about their every day lives. EVIDENCE: The inspector sampled the personal files of two service users. Each contained an up to date care plan. Where possible service users are involved in the creation of the care plan. One care plan seen gave evidence that the service user had been able to add their comments and thoughts on the care plan and had been fully involved in the review of their placement. 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 12 All care plans also contain comprehensive risk assessments in respect of the individual and activities undertaken both in and out of the home. Some risk assessments were not dated therefore it was difficult to tell if they accurately reflected current assessed risks. There were also no review dates. The manager explained that all reviews are in a separate file, however service users files should clearly state that the assessments have been reviewed and are up to date. Care plans seen were well written and comprehensive covering a wide range of issues. Care staff spoken to stated that they spent time reading care plans and found them up to date and reflective of the needs and abilities of people living at the home. Daily records are written about service users and any significant events are recorded. Each month keyworkers write a summary about the service user. Staff stated that care plans are always changed if there are any changes in need or wishes. The inspector observed that staff offered choices to people at lunch-time by showing service users different drinks or fruit to choose from. Since the last inspection the home have looked at ways of involving service users in choosing meals. Service user meeting are held on a monthly basis and each week two service users go shopping with staff for the weeks groceries which is another opportunity for people to make choices about food coming into the home. It was noted that service users are able to make choices about how they spend their time and are able to spend time quietly in their rooms if they wish to. The company acts as an appointee for service users in respect of the Department of Work and Pensions. The home keeps small amounts of money to ensure that people are able to purchase items when they wish to and have access to facilities. The inspector viewed the records in respect of these monies and found that there was a clear audit trail. Money checked correlated with records kept. All service users have bank accounts which require two signatures to make withdrawals. One of the signatories no longer has regular contact with the home, although they still work for the company, which makes it very difficult for service users to withdraw money. 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 13, 14, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to take part in a wide range of activities and are encouraged to take part in the day to day running of the home. There are ample opportunities for people to access community facilities. EVIDENCE: Service users are encouraged to take part in day to day household chores in line with their individual abilities. Staff stated that some service users assisted with cooking and clearing up after meals. All staff spoken to demonstrated an ethos of enabling service users to learn and develop independent living skills by taking part in the day to day running of the home. The inspector observed that staff assisted service users 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 14 to keep their rooms tidy. As previously stated service users are now assisting with the weekly food shopping. Currently no service users attend further education or paid employment outside the home. There are a range of leisure activities arranged in line with individual likes and preferences. On the day of the inspection one person went out horse riding, one went to a toning table session and another walked up to the local shop with a member of staff. Staff spent time at the home chatting with service users, assisting people with puzzles and manicuring nails. The home has two vehicles and a dedicated activity budget. Staff stated that they try to ensure that everyone has opportunities to go out to places that interest them. They aim to have one large trip out each month in the summer and smaller trips on a daily basis. There are some social events arranged which all homes within the company are able to attend. A Summer Ball has been arranged for the near future. All service users are able to have an annual holiday varying in length. This year people living at the home are going to Cornwall in small groups, or individually, with staff support. Service users are able to have visitors at all reasonable times and at the time of this inspection one person was away staying with family. The deputy manager stated that families visiting are able to have lunch at the home. In addition to the main lounge there is a small communal lounge where service users can see visitors in private or spend time doing activities such as art and craft. There is a five week menu that provides a wide variety of meals. The main meal is at mid-day with service users and staff sitting together in a large dining room. Menus are determined by known likes and dislikes. There is no choice on the menu but staff stated that they are always able to make an alternative for anyone who did not wish to have the meal on the menu. The inspector was able to join service users for lunch and noted that people were assisted to eat in a way that respected their dignity. 52 Wellington Road DS0000039964.V344484.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. Service users receive assistance with personal care in a way that respects their privacy and dignity. Service users have access to healthcare professionals in line with their individual needs. EVIDENCE: Care plans give details of level of support service users require with personal care. This ranges from prompting to full physical assistance. All bedrooms have en suite facilities where service users can carry out personal care tasks in private. The home employs both male and female staff meaning that service users are able to choose the gender of the person who assists them with intimate personal care. 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 16 All appointments with healthcare professionals are recorded and these showed that service users are accessing GPs, psychiatrists, chiropodists, dentists and opticians. Staff assist service users to attend appointments outside the home. The area manager stated that the company employs a behavioural therapist who the home have access to for support and advice. The healthcare professional who completed a questionnaire prior to the inspection answered YES to the questions “Do staff demonstrate a clear understanding of the care needs of service users?” and “If you give any specialist advice is it incorporated into the care plan?” Currently no service users living at the home administer their own medication. There is appropriate secure storage for medication and only senior staff who have received training have access. The home uses a Monitored Dosage System (MDS) for medication. The inspector viewed the Medication Administration Records (MARs) and found them to be generally well maintained and correctly signed when administered or refused. All medication received into the home is signed in giving a clear audit trail. There were some hand written entries on the MAR charts that had not been signed and witnessed in line with good practice guidelines. There are protocols in care plans for medication that is prescribed on an ‘as required’ basis (PRN) The one seen by the inspector had not been dated. 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has taken reasonable steps to minimise the risks of abuse to service users. EVIDENCE: The home has policies and procedures on making a compliant, recognising and reporting abuse and whistle blowing. Staff spoken to were aware of the ability to take serious concerns outside the home. All were clear that they were able to contact the Commission for Social Care Inspection with any serious concerns. All eight staff who completed questionnaires prior to the inspection stated that they received information about how to report concerns about poor or abusive practice. The inspector noted that the whistle blowing policy had been discussed at a recent senior staff meeting. A complaints log is maintained but no complaints have been received by the home since the last inspection. Both service users who completed questionnaires prior to the inspection answered YES to the questions “Do you know how to make a complaint?” and “do the staff listen and act on what you say?” 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 18 Service users are able to move freely around the home. Coded keypads are fitted on bedroom doors but these are not activated when service users are coming and going throughout the day. Some service users are able to remember the codes and one person has a key to their room instead of a keypad. The inspector observed that people were able to spend time in their rooms if they wished to. The home use door alarms for some service users to ensure that staff are able to quickly respond and assist if people leave their rooms. Staff were seen to interact with service users in a respectful friendly manner. For service users who are unable to express themselves verbally care plans gave details of how to recognise when someone is unhappy or possibly in discomfort. Care staff gave evidence that they were familiar with individuals non verbal communication and how to respond. All staff were clear that they do not use physical intervention with any service user, all receive training in Non Violent Crisis Intervention (NVCI.) Many of the staff working at the home have received training in the protection of vulnerable adults and it is an expectation that all staff will undertake this training. There is a robust recruitment procedure and no new members of staff start work until they have been checked against the Protection Of Vulnerable Adults (POVA) register and have undergone an enhanced Criminal Records Bureau (CRB) check. 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 52, Wellington Road provides a comfortable environment for service users. Some bedrooms and en suites would benefit from redecoration. EVIDENCE: 52 Wellington Road is a large Victorian house set along the main road into Taunton. It is within walking distance of shops and other amenities. All areas are fitted with a fire detection and emergency lighting system, which is regularly tested by staff at the home and serviced by outside contractors. Service user accommodation is set over three floors with all communal seating areas on the ground floor and accessible to people with all levels of mobility. At 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 20 the time of this inspection new furniture had been purchased for the main lounge and was being stored in the quiet room temporarily. There are gardens to the front and rear both with seating areas. All bedrooms are for single occupancy and all have en suite facilities. Rooms are decorated when new people move to the home and most are decorated to a good standard. The inspector saw two bedrooms and en suites, belonging to people who had lived at the home a long while, that were in need of redecoration. Service users are able to personalise their rooms and some have purchased their own furniture. All bedrooms are an adequate size to enable people to have TVs and music equipment. There is a small laundry area that is appropriate to the needs of the home. There is one washing machine, one drier and adequate hand washing facilities. All areas seen by the inspector were clean and fresh. 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are well motivated and enthusiastic about their jobs. All receive regular formal supervision. Many staff felt that they would benefit from further training appropriate to their role in the home. Recruitment procedures are robust and minimise the risks of abuse to service users. EVIDENCE: The home employs 20 support workers and are in the process of recruiting a further 3. Currently only 5 members of the team have a National Vocational Qualification (NVQ) in care. The manager stated that a further nine people are registering for NVQ level 2. 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 22 All staff spoken to felt that the home was adequately staffed to meet the needs of the service users. On the day of the inspection there were five staff on duty, including the deputy manager. (Overnight there are two waking night staff.) Care staff are also responsible for the cooking, cleaning and laundry in the home. During the inspection all service users appeared to have appropriate access to staff. People were able to go out with supervision and spend time with staff in the home. There was a calm relaxed atmosphere with staff interacting well with service users. Some staff expressed concerns about the lack of opportunity for training. Some staff felt that they would like further training in communication; Senior staff, who take responsibility for the whole home in the absence of the manager or deputy, felt that they would benefit from additional training such as NVQ level 3 in care. Specialist training had been provided for all staff in preparation for a new service user who moved to the home recently. One member of staff stated that training needs identified in supervision were not always actioned. Staff stated that they were paid to attend training sessions. At the last inspection a requirement was made to ensure that all staff were provided with mandatory training up dates. This requirement has been complied with. Staff have now completed training in health and safety, fire safety, food hygiene and first aid. 8 members of staff completed questionnaires prior to the inspection. 7 felt that they had received adequate induction and supervision when they commenced work at the home. During the inspection the inspector was able to view the recruitment and induction record, and speak with, the most recently appointed member of staff. The recruitment file gave evidence of a thorough recruitment process with written references being sought and appropriate checks in place. The staff member felt that they had received a good induction and had been well supported by more experienced staff. All staff spoken to were well motivated and had an obvious commitment to providing a high quality service. All stated that they received regular supervision and that team meetings were an opportunity to share ideas and opinions. People felt that all staff worked as a team and communicated well. One care/relative wrote on their questionnaire that “staff display a high degree of skill and professionalism” and another said that “the staff are exemplary.” 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 38, 39, 41 & 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 run in a way that takes account of the views of staff and service users. Reasonable steps have been taken to ensure the health and safety of service users. EVIDENCE: There is currently no registered manager at the home. The manager has been in post for over six months and has applied to the Commission for Social Care Inspection to be registered. The manager was not available on the day of the inspection. 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 24 There are clear lines of accountability in the home with a manager, deputy and senior support workers. Staff who completed questionnaires stated that there was always a senior member of staff on duty and the healthcare professional who completed a questionnaire answered YES to the question “Is there always a senior member of staff on duty to confer with?” All staff described the new manager as open and approachable. All stated that they felt that their views and the views of the service users were listened to and influenced the running of the home. One care/relative wrote on their questionnaire that “the management can not be faulted.” The company has systems in place to audit the quality of care, these include monthly visits and annual service reviews which include the views of service users, families and professionals. All records are securely and appropriately stored all those viewed by the inspector were well maintained and up to date. Appropriate measures are in place to maintain health and safety within the home. Fire records demonstrate that alarms and emergency lighting is tested on a weekly basis by staff at the home and the system is regularly serviced by outside contractors. All staff have received training in fire safety within the last 6 months and there are recorded evacuations of the building. Water temperatures in en suite facilities are taken daily to prevent the risk of scalding. Fridge, freezer and food temperatures are taken and recorded in line with good food hygiene practices. Records were seen of testing in respect of portable electrical appliances, the electrical installation and there is an up to date landlords gas certificate. 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 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 3 26 2 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X X 3 3 X 3 3 X 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 26 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. 1 Refer to Standard YA20 Good Practice Recommendations All hand written entries on Medication Administration Records should be signed and witnessed. Protocols for the use of PRN ‘as required’ medication should be dated and give evidence of regular reviews. All bedrooms should be well maintained and redecorated as appropriate. Staff should undertake National Vocational Training appropriate to their level of responsibility in the home. All staff should have access to training courses appropriate to their needs and role within the home. 2 3 4 YA26 YA32 YA35 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 27 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 52 Wellington Road DS0000039964.V344484.R01.S.doc Version 5.2 Page 29 - 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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