Inspection on 15/05/07 for 54 Leylands Road

This inspection was carried out on 15th May 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

54 Leylands Road 10/10/06

54 Leylands Road 16/01/06

54 Leylands Road 22/08/05

54 Leylands Road 09/11/04

54 Leylands Road 29/06/04

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

CARE HOME ADULTS 18-65 54 Leylands Road 54 Leylands Road Burgess Hill West Sussex RH15 8AL Lead Inspector Mrs A Peace Unannounced Inspection 15th May 2007 09:00 54 Leylands Road DS0000014663.V336083.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 54 Leylands Road DS0000014663.V336083.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. 54 Leylands Road DS0000014663.V336083.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 54 Leylands Road Address 54 Leylands Road Burgess Hill West Sussex RH15 8AL 01444 870546 01444 254740 leylands54@sussexoakleaf.org.uk 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 Oakleaf Housing Association Limited Mr Prabhooraj Unmar Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) 54 Leylands Road DS0000014663.V336083.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th October 2006 Brief Description of the Service: 54 Leylands Road (previously registered as Peppers) is a care home registered for up to six service users in the category of mental disorder (excluding learning disability or dementia), one of who can be in the category of mental disorder over 65 years of age (excluding learning disability or dementia). The registered provider is Sussex Oakleaf Housing Association Limited, for whom the Responsible Individual is Mr Neil Perkins. The registered manager is Mr Prabhooraj Unmar. The current scale of monthly charges range are approximately £1118.00 Additional charges are made for personal items. 54 Leylands Road is a detached property, with accommodation provided over two floors. In addition there are gardens that can be easily accessed by the residents. The home is located in a residential area of Burgess Hill, with easy access to nearby bus and train services. The Service Users Guide and Statement of Purpose can be located at the home, and are accessible to Service Users, staff, relatives and anyone else interested in the service. 54 Leylands Road DS0000014663.V336083.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mrs Ann Peace Regulatory Inspector carried out this unannounced key fieldwork inspection on 15th May 2007. This is the first inspection for the year 2006-2007. It is called a key inspection and will determine the frequency of visits/inspections hereafter. Prior to the inspection, records and information held on file and information were reviewed. The Manager Mr Unmar completed the assessment documentation as required and returned it to the Commission before the inspection. Six residents were accommodated at the home on the day of the inspection visit. During this visit the Inspector toured the building and visited three bedrooms with the permission of the residents. A case tracking exercise was undertaken for three residents and the other records were examined briefly. The tracking exercise looked at records and tracked the records to the care given for individual needs identified. The records are comprehensive and up to date. Three residents were spoken with and said that they were happy at the home and felt safe and well supported by the manager and the staff. What the service does well: The home actively encourages residents to lead an independent life and to pursue activities of their choice; they are supported by a well-trained staff team and a dedicated manager. The home is clean, comfortable and has a homely atmosphere and residents are encouraged to personalise their rooms according to their tastes. Regular meetings are held for residents to express their views and residents do have access to outside forums provided by the company. The home does take part in activities in the local community and have recently won a best in bloom competition for their garden. 54 Leylands Road DS0000014663.V336083.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. 54 Leylands Road DS0000014663.V336083.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 54 Leylands Road DS0000014663.V336083.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): 1,2,3,4,5. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Prospective resident’s individual needs are assessed prior to admission to ensure the home will be able to meet their needs. An up to date Statement of Purpose and Service Users Guide is available so they can make an informed choice. Residents have a contract which clearly tells them about the service they will receive and what they will be charged for the service, these are signed and dated. EVIDENCE: A comprehensive and current Statement of Purpose and Service Users Guide is available to prospective residents and other interested parties. These documents include the aims, objectives and philosophy of the home and information about the environment and facilities to help prospective residents or their representatives make a judgement if the home would be suitable for them. One minor concern regarding confidentiality was identified during the visit, however this was amended during the inspection by Mr Unmar the registered manager. 54 Leylands Road DS0000014663.V336083.R01.S.doc Version 5.2 Page 9 The results of a satisfaction survey are available and on display but this was for 2005. A new one is planned for June 2007. Information about the residents is gathered through individual needs assessments and and risk assessments taking into account the residents wishes. This is in discussion with residents and their representatives and this information is used to create an individual person centred care plan. All of the care records examined are up to date. Staff training is provided to meet identified needs. Prospective residents are visited by two home managers who carry out a needs assessment to ensure they will be able to meet the needs of the prospective resident. Trial visits can be arranged for a day, overnight or weekend visits. The residents have their own bedrooms. They have a licence agreement which give them certain rights as a tenant. Signed and dated contracts were seen and included the fees. Residents are also assessed for their ability to manage finances, if they need help they sign a form for staff to help and records are kept, these were seen during the visit. Individual personal financial files are kept and these are up to date. 54 Leylands Road DS0000014663.V336083.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): 6,7,8,9,10. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Resident’s assessed and changing needs are recorded in individual person centred plans of care and they play an active part in planning the care and support they need. Residents are supported and encouraged to have an independent lifestyle and take control of their live, risks are identified and managed. Residents are supported to make decisions about their lives, are involved in the running of the home and said their decisions are respected. EVIDENCE: Mr Unmar said that the ethos of the home is to give all service users dignity, respect, rights and to promote independence towards recovery, from evidence gathered during the visit we concluded that it did. The care records of all six residents were seen, these are up to date. Records and verbal confirmation from residents showed that residents are involved in 54 Leylands Road DS0000014663.V336083.R01.S.doc Version 5.2 Page 11 the planning of their care and are involved in the regular reviews to monitor their health and well being. The care plans are person centred and residents are encouraged to take control of their own lives to promote independence. Staff were noted to encourage residents to make decisions and choices while also sensitively ensuring that they take responsibility for some tasks they needed to carry out such as their own washing, making their bed and cooking. On the day of the visit one resident had gone swimming and another to a voluntary job. One resident was going out to an optician’s appointment and was escorted by a member of staff. Other residents were pottering about in their rooms or in the kitchen. One resident was due to go to a meeting with MIND in the afternoon. There is a key worker system operated and key staff contribute to the care plans and the reviews on a regular basis. A board in the kitchen records which staff are on duty for the different shifts that day and the menu for the day for those who do not cater for themselves. Training records indicated that staff have the skills to support residents. During the visit staff interactions with residents were friendly and professional and residents were at ease with staff. Residents spoken to say staff treat them well and support them. Residents are supported to take calculated risks. The management of risk is comprehensive and records the benefits of risk, arguments against risk, outline of risks, action to minimise risks and emergency contacts. These are reviewed on a regular basis. All risk assessments are up to date. Residents are consulted on a monthly basis during residents meetings. Records of the meetings were seen and these included any action or changes needed which did show that the opinions of residents are respected. Residents when asked if there was anything they could change what would it be and both said they were happy with the way things are. They like living at the home and the staff treat them well. Written procedures for unexplained absences are in place providing a clear process for staff to follow and there is also an emergency on call system operated. 54 Leylands Road DS0000014663.V336083.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Residents are encouraged and supported to make choices about their lifestyle and routines in the home are flexible. There are opportunities for personal development, social educational and recreational activities to meet their identified needs. Residents are supported to plan, prepare and serve healthy meals. EVIDENCE: Records indicated that residents are supported to identify their goals and wishes and work towards them. Two residents confirmed this during the visit. There are two communal rooms for residents to use, one lounge and a conservatory, both have televisions which residents can use if they wish. One room has a personal computer for residents use and one resident keeps a static bicycle for exercise in the conservatory. 54 Leylands Road DS0000014663.V336083.R01.S.doc Version 5.2 Page 13 Residents can follow their own interests in the daytime according to their risk assessments and capability. Records indicated that training is encouraged and one resident had recently attended a training course at a local college. There are posters in the home displaying various local courses and day centre activities. On the day of the visit three residents were out and about and three pottering about in the home. One was doing his washing. Some residents are involved in working in the garden with the help of a volunteer and their garden has recently won the local “Garden in Blooms” competition. They are due to pick up their award in the near future. All residents are involved in domestic routines of the home, four residents self cater, with staff cooking for two residents. Residents plan their own menus and cook the food that they like. Support plans in place for service users to self cater allowing them to manage their food budget and to have more choice. Mr Unmar said residents usually eat their evening meal and Sunday dinner together. Individual shopping lists were seen; residents can have their own storage space for food. Residents have their own unopened post in a tray in the hallway, they all have a key to the front door of the home and they can lock their rooms if they wish. There is a communal payphone in the hallway for residents to use. A notice board in the hall displays helpline numbers, information on how to contact an advocate, general fire procedures, guidance on sharing a home and a health and safety poster. A canal boat holiday is planned for this year for 4 residents and individual care records showed that residents do go out to London and visit other places. At present residents can smoke on one of the lounges and in their rooms, however this is presently being reviewed. Family and friends are welcome to come into the home if the residents wish and they can visit in privacy in resident’s rooms. 54 Leylands Road DS0000014663.V336083.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The health and personal care that residents receive is based on their individual needs and staff give residents physical and emotional support with assistance from other health professionals when needed. The home operates robust and safe medication procedures. EVIDENCE: The care plans record specific health care, personal care and social care needs that staff need to assist residents with. In most cases the input for personal care is minimal. During the inspection a member of staff was noted to actively encourage a resident to care for himself. The care records give a view of the overall health and well being of residents and any changes that have been noted. The mental health reviews are carried out on a regular basis and record input from key workers and other health professionals as well as the residents. Residents are invited to all of the meetings related to their health and wellbeing. 54 Leylands Road DS0000014663.V336083.R01.S.doc Version 5.2 Page 15 The home gives personal support relating to individual needs including hygiene needs and evidence of this was seen on the day of the visit this was also backed up by speaking to the residents. Flexible routines for getting out of bed, mealtimes, activities and going to bed are respected. One resident is having a more formalised care package with timed regimes which he has agreed to. Records are kept of other healthcare, social or specialist visits to residents. Staff training has improved since the last inspection and all staff now have had comprehensive training to be able to look after residents. The home has a very efficient medication policy, all staff have had recent training in administration of medication and related procedures and staff were seen to follow safe procedures during the visit. Medication is stored in a locked metal cabinet and located within the office that is also kept locked. On examination of MAR sheets there were no gaps in signing and written records were good. The storage of medication was very tidy and orderly. 54 Leylands Road DS0000014663.V336083.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Residents are able to express concerns to staff and there is a complaint procedure operated in the home. Staff are trained in safeguarding vulnerable adults from abuse and residents did say they felt safe. EVIDENCE: Since the last inspection a book noting minor concerns has been opened. There were some entries in there but all had been dealt with in house. No formal complaints are recorded and CSCI has not received any. The complaint procedure is displayed in the hallway of the home and the three residents spoken to said they would complaint to any of the staff or Mr Unmar if they needed to. At the last inspection residents said that they did not think their concerns were listened to. However on this visit the three residents said that staff do listen and do taken action if needed although no one could site an example. The residents meeting minutes were seen and did record open dialogue between residents and staff. Two of the residents were asked if they felt safe at the home and they both said yes. All staff had a record of up to date training in the safeguarding of vulnerable adults and a member of staff on duty did know the correct procedure to follow. 54 Leylands Road DS0000014663.V336083.R01.S.doc Version 5.2 Page 17 A copy of the local authority procedure to safeguard vulnerable adults is in the main office for staff to refer to. 54 Leylands Road DS0000014663.V336083.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): 24,25,26,27,28,29,30. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Residents live in a clean, homely, comfortable and safe environment and their bedrooms suit their individual tastes. EVIDENCE: 54 Leylands Road is a large detached house with accommodation provided over two floors. It is surrounded by its own gardens and in addition has a large area designated to car parking. Communal space is plentiful, consisting of lounge, kitchen/diner, conservatory that is also used as an activity room, and a good size garden. There is a large laundry room which one resident was using independently during the visit. The Garden is being well maintained by a volunteer gardener with the help of residents. It has recently won a local “Gardens in Bloom” competition; the award ceremony is due to be held the week following the visit. 54 Leylands Road DS0000014663.V336083.R01.S.doc Version 5.2 Page 19 The garden is planted with flowering shrubs and flowers and there is an ornamental pond with fish. There is garden furniture for residents who wish to sit outside and there is a BBQ which residents said is used in the good weather. To the side of the building there is an allotment area where fruit and vegetables are being grown. The home is clean, bright, homely and comfortable. With the permission of residents three bedrooms were visited and were found to be personalised to suit individual tastes. An inventory of Service Users’ furniture is on their personal files. Bedrooms can be redecorated and refurbished to the resident’s choice. Mr Unmar said that in the next 12 months the internal environment is to be redecorated and refurbished as necessary involving the residents. They plan to fix new fencing to the front of the home to provide more privacy, extend the garden and reduce the noise from the traffic 54 Leylands Road DS0000014663.V336083.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): 31,32.33.34,35,36. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Staff in the home are well managed, trained, skilled and in sufficient numbers to support and protect the residents accommodated. Residents are protected by the robust recruitment policies and practices operated in the home. EVIDENCE: Duty rotas record that two staff are on duty the majority of times. During the night there is one sleep-in carer and one awake. The manager said that at present due to staff shortages he has to fill in for the occasional shift. On the day of the visit the registered manager was on duty with a bank member of staff who has been working at the home for many years in a part time capacity. She was very knowledgeable about the residents and obviously knew them well and they were at ease with her. There was also an area manager in the home who had booked herself onto a shift at the home to see what it is like to work at the home. 54 Leylands Road DS0000014663.V336083.R01.S.doc Version 5.2 Page 21 All of the staff had up to date training in fire, health and safety, food handling, first aid, manual handling, adult protection, medicines, professional boundaries and mental health. There was a poster displayed about training on the new Mental Capacity Act. One member of staff did confirm training had been given in dealing with challenging behaviour and risk management and said that in supervision Mr Unmar always ensures that staff are aware of the risks and how to deal effectively with them. Staff are encouraged to undertake external qualifications and over 50 of the care staff have achieved a national vocational qualification. There is a robust recruitment policy in place which protects residents; all staff have appropriate safety checks and documents in place as well as induction training. Two residents said the manager and staff support them, are friendly and easy to talk to. Staff meetings take place monthly and minutes of these were seen. There is a staff forum in operation and there is also a record of a team-building day that had been arranged. A staff supervision and appraisal system is in place in the home and records of supervision sessions are available. Mr Unmar stated that in future residents would be involved in the recruitment of staff if they wish. An Equality and Diversity Toolkit has been been developed for use in staff meetings to highlight the responsibilities of staff to promote equality and meet diverse needs. There is also a corporate Equality and Diversity Policy/Strategy and an Anti Discriminatory Practice Policy in place. An Equality and Diversity Working Group is looking at issues that need addressing and in the future they plan to promote awareness by offering training to staff; this will benefit residents with diverse needs. 54 Leylands Road DS0000014663.V336083.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The home is very well run; Mr Unmar the registered manager is qualified competent and experienced to run the home and the residents and staff benefit from his leadership and management approach. Residents are listened to and their views taken into account in the running of the home. Policies and procedures are followed which ensure the safety of residents and staff and record keeping is to a good standard. Through staff training the health safety and welfare of residents are promoted and protected. EVIDENCE: 54 Leylands Road DS0000014663.V336083.R01.S.doc Version 5.2 Page 23 Mr Unmar is a qualified mental health nurse; he has experience of working with people with mental health needs and has been at the home 6 years. He has a management qualification as well as the registered managers award. The home is well run and the residents and staff benefit from Mr Unmar’s management approach and leadership skills, staff and residents said they felt well supported. There is a quality assurance system in place but there was not a survey carried out in 2006, the latest feedback with published results which were on display in the home was 2005. Mr Unmar said they are going to carry out a full survey in June 2007. The company has various ways of getting feedback from residents and their representatives. They hold an annual residents forum and any resident can attend. Residents lead the meetings and they incorporate workshops that cover a range of issues. Mr Unmar has a clear understanding of the corporate provider for the home and implements their policies and procedures to the benefit of the residents and staff. Residents have 1:1 meetings with staff and take part in Family Group meetings. Relevant policies are discussed at resident’s meetings and comments are reported back to the Senior Management Team. There is an open and transparent attitude to the running of the home and residents are involved in all decisions regarding the home. Mr Unmar is aware of the current developments both nationally and by CSCI and the future changes that it will bring. The service has sound policies and procedures which have been reviewed recently. Residents also have access to the policies and procedures, some residents signatures were seen. Management processes through supervision and appraisal ensure staff receive feedback on their work. Insurance cover is in place to fulfil any loss or legal liabilities. Records are of a good standard and are routinely completed, residents are aware of the health and safety issues and are expected to abide by rules which protect them. Various posters and guidelines are available around the home to inform them of risks. Individual risks are also documented in the personal files. The home keeps up to date records of transactions and these were audited on the day of the visit and were in order. Residents said they are listened to and changes do take place as a result. The company carries out visits to assess the conduct of the home on monthly basis. Fire safety training is carried out at required intervals and fire safety systems tested. Mr Unmar was advised to contact the local fire service for advice about how often the emergency lighting needs to be tested, contractors presently do it three monthly. A list of in house safety checks are recorded. 54 Leylands Road DS0000014663.V336083.R01.S.doc Version 5.2 Page 24 54 Leylands Road DS0000014663.V336083.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 3 5 3 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 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 x 4 3 3 3 3 3 3 54 Leylands Road DS0000014663.V336083.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 YA42 Good Practice Recommendations Mr Unmar to contact the local fire service for advice regarding the testing of the emergency lighting in the home. 54 Leylands Road DS0000014663.V336083.R01.S.doc Version 5.2 Page 27 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 54 Leylands Road DS0000014663.V336083.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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