Inspection on 22/01/07 for 55 Drubbery Lane

This inspection was carried out on 22nd January 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

55 Drubbery Lane 16/12/05

55 Drubbery Lane 23/09/05

55 Drubbery Lane 07/12/04

55 Drubbery Lane 07/07/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 55 Drubbery Lane 55 Drubbery lane Blurton Stoke on Trent Staffordshire ST3 4BH Lead Inspector Ms Wendy Jones Key Unannounced Inspection 22 January 2007 14:00 55 Drubbery Lane DS0000008245.V302449.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 55 Drubbery Lane DS0000008245.V302449.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. 55 Drubbery Lane DS0000008245.V302449.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 55 Drubbery Lane Address 55 Drubbery lane Blurton Stoke on Trent Staffordshire ST3 4BH 01782 311324 F/P 01782 311324 h6026@mencap.org Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Royal Mencap Society Mrs Julie Hawley Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places 55 Drubbery Lane DS0000008245.V302449.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th December 2005 Brief Description of the Service: 55 Drubbery Lane is registered to provide care for 5 adults with learning disabilities and associated physical disabilities, although the current design and usage is suitable only to accommodate 3 people in single bedrooms (there were previously 2 double bedrooms). The possibility of converting the large garage/carport area to increase the number of bedrooms has been discussed in the past, but the current situation seems to be that a decision has been made that the accommodation is to be vacated and service users relocated. The Commission for Social Care Inspection have not be formally notified of this, but relatives and service users are aware of the proposals for the future of the home. They must be fully consulted and have an opportunity to state their views. There are currently 3 service users; two have lived at Drubbery Lane since it opened 15 years ago. The home is managed by the Mencap Homes Foundation and was initially developed to relocate people who were in long-stay hospital care. The home is a spacious and carefully adapted bungalow situated in superb extensive grounds. All 3 service users have wheelchairs for mobility and all areas of the home and grounds are easily accessible. The home is situated in a residential area with good access to all main towns. 2 people-carriers adapted for wheelchair users are available. There are 3 spacious bedrooms one has large en-suite facility, all have adequate space for wheelchair use, hoist etc. There is a large lounge/dining area overlooking the garden. There is a communal bathroom with assisted facility and separate toilet areas. There is a large kitchen area, a laundry and office accommodation. Furniture, fittings and equipment are to a generally high standard. The weekly rent for the home was quoted as £62.35-£73.25. 55 Drubbery Lane DS0000008245.V302449.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection visit; the site visit was conducted over two days from the 22 January 2007 and the 26 January 2007 when feedback was given to the manager. The inspection process has included collation of pre inspection information, discussion with other interested parties; feedback from service users, relatives, visitors and a social worker. All three service users were in the home at some point during the site visit and were asked for their opinion on the care they had received. They had also been supported by staff to complete questionnaires, which were returned to the CSCI prior to this visit. Comments included, “I like living here”, “Staff treat me well and listen to me,” “ I can choose what I like to do, I feel safe at this home,” all three service users stated that they didn’t have a key to their bedrooms, in the questionnaires. Three relatives comments cards were returned all made positive comments about the service including, “I have always been made welcome,” “the staff are always very professional.” “I have never felt the need to raise any concerns.” A social worker also stated that during her involvement in the home, she had been happy with the level of support and the care service users were receiving. What the service does well: The environment was of a good standard and had been adapted to make it easily accessible for all 3-wheelchair users in the home. Service users were involved with their care planning and knew who their key workers were. There was evidence of regular reviews of care and person centred planning was in place. Medication storage and management was of a particularly high standard, and the manager should be commended on her diligence in this area. Staff were knowledgeable of the care needs of service users and gave positive accounts of the steps they take to ensure that all needs are appropriately met. And staffing levels were sufficient to provide almost one to one staffing ratio for periods of time throughout the waking day. Service users were happy with the care and support they received from the care team. Throughout the visit there was evidence of positive relationships. The manager demonstrated a good management style and ability to lead a team. Policies and procedures were in place. 55 Drubbery Lane DS0000008245.V302449.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. 55 Drubbery Lane DS0000008245.V302449.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 55 Drubbery Lane DS0000008245.V302449.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 The quality outcome of this standard was good. This judgement was based upon, the evidence provided from discussion with service users and the information available in records. Prospective service users are given the opportunity to visit and spend time in the home. They and their carers are given relevant information to help them understand how the home is organised and run and the facilities and services that are available. EVIDENCE: The home has a Statement of Purpose, that is on display in the main hallway of the home, each of the service users have a their own copy of the service user guide. The manager stated that it’s content had been discussed with them, and there was evidence that efforts had been made to produce it in a more user friendly form for the benefit of the service users at the home. Matters arising included the need to ensure that both documents accurately reflected the requirements of the care homes regulations in that the Statement of Purpose included the details of the Commission for Social Care Inspection and the Service User Guide must included details of fees charged for the service. During this visit two service users were spoken to in detail, one of whom had been admitted to the home within the last 18 months. She confirmed that she had been involved with making the decision to move into the home and had 55 Drubbery Lane DS0000008245.V302449.R01.S.doc Version 5.2 Page 9 been supported by her family. She also confirmed that she had received relevant information regarding the type of service it’s facilities etc before agreeing to move in. She described the experience as positive and expressed satisfaction with the service and care she had received. 55 Drubbery Lane DS0000008245.V302449.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 The quality outcome of this these standard was good. The information provided in care records was of a high standard throughout and clearly identified how the needs of service users were being met. EVIDENCE: A sample of assessments, care records, plans and person centred information was seen during this visit, the inspector had an opportunity to talk to a service user about the files containing this information. Care records are seen as the service user’s property and stored in individual bedrooms, the service user said “ I know who my key and co-worker are, and they talk to me about things I like doing and want to do”. This was confirmed from the records of monthly key workers reports, seen in the files. The standard of care planning throughout was excellent. A sample of PCP’s showed that the last meeting had taken place in 2005, it is recommended that at least an annual review is arranged. Support plans were in place and provided detailed information about the care needs of the service user and what staff should do to properly meet their needs. The 24 hour plans of care gave an explicit account of the individuals preferred routines and there 55 Drubbery Lane DS0000008245.V302449.R01.S.doc Version 5.2 Page 11 was evidence in the records that the service had sought support from independent advocacy services where appropriate. A sample of the financial records of service user were seen during this visit, a problem had arisen due to staff sickness and the rules of the local building society regarding signatories to the service users account. This meant that staff had not deposited monies for the service user, because of the difficulties withdrawing the money if needed, as the person off sick was the only signatory. This had resulted in the service storing money on behalf of the service user over and above the insurance limit for individuals. This matter must be resolved for the benefit of the service user. The organisation should consider reviewing the current signatory arrangements to ensure that similar difficulties do not occur again, it should be noted that the manager stated that the difficulties had arisen due to the banks requirements. Risk assessments identified individual and more general risks, and provided staff with the information they need to minimise or eliminate the identified risk. The records showed that the assessments were regularly reviewed. 55 Drubbery Lane DS0000008245.V302449.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17. The quality outcome for these standards was good. This judgement was determined from the evidence of the information provided and from discussion with service users and staff. Service users are supported to participate in activities in and out of the home but would benefit from a more varied range. EVIDENCE: One service user has two sessions per week at college, 1 service user has one session of hydrotherapy, another service user has two sessions of hydrotherapy each week. These sessions appear to be the only regular occupational/educational/therapeutic activities. One service user said “I like going to Tesco’s.” The records that showed that a weekly library session had been included in the service user’s pre planned diary. But there did not appear to be any evidence that the service user had visited one, in the day-to-day records available. This was discussed with the manager who explained that the individual had become quite rigid over the type of activities he liked to do and did not enjoy changes to his preferred routine. The library visits remain on the plan to provide the service user with a choice of activity. 55 Drubbery Lane DS0000008245.V302449.R01.S.doc Version 5.2 Page 13 The records also showed that some of therapeutic activities service users had arranged had been cancelled either by the service or by the provider, and in one example, physiotherapy sessions had been suspended due to poor attendance. The manager cited a lack of staff drivers on occasions as a reason for this, but agreed that where possible the staffing arrangements should be adequate to ensure that service users did access all the sessions they had planned. The level of occupational and educational activities was adequate but could be improved, with service users spending large parts of their day engaged in fairly passive activities in the home, such as listening to music and watching TV. It is accepted that these are activities were recorded in service users files as things they enjoy. This was confirmed from discussion with service users. But one service user did suggest that more staff could be deployed in the evening so that she could go out then. This was discussed with the manager during feedback. Information available showed that service users had meetings 4 times per year, although the detailed records were not seen during this visit. Two service users confirmed they had these meeting to talk about food, and things they wanted to do. Two service users also said that they had been on holiday in October 2006 for a long weekend, both stated that they had enjoyed it and wanted to go away again this year. Service users said that they could choose their meals, this was confirmed from the sample of menu’s seen. Service users also had full access to the kitchen. Fresh fruit was freely available and efforts were made to encourage service users to eat healthily. Staff observed that as the service user group were wheelchair dependent, monitoring dietary intake was particularly important to assure there health and well being. Two service users confirmed that they were supported to maintain family relationships and other friendships on a regular basis. One service user showed photographs of relatives and talked about meeting them and talking to them on the phone. 55 Drubbery Lane DS0000008245.V302449.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 The quality outcome for this area was good. This judgement was based upon the evidence from the information in service users health and medication records. The health and personal care that service users receive is based on their individual assessment of need and delivered in such a way that there was evidence that service users were being well cared for. EVIDENCE: Service users all had an allocated key worker, and those service users spoken to knew who their key worker was, and also confirmed that they met with them on a regular basis to discuss what they wanted to do. A sample of care records showed that service users were supported to attend regular health related appointments and check ups, all were registered with a GP and other primary care providers. There was also regular input from specialist health professionals. The systems for the safe administration, recording, handling and storage of medication were good, records were properly signed and in keeping with the service’s standards, for two staff to sign them. Robust policy and procedures were also in place. There were protocols for the administration of medication, 55 Drubbery Lane DS0000008245.V302449.R01.S.doc Version 5.2 Page 15 service user photographs, and updated information about the current prescribed medication for each service user. Where there was a known allergy there was relevant information to alert staff. The stock control systems were good with evidence of the medication coming into the home, and of that returned to the pharmacy. The manager had made every effort to ensure that the possibility of errors was kept to a minimum. Each service user had a letter confirming that the GP had agreed that some over the counter remedies could be administered, while this is considered good practice, it was also recommended that a specific list of these remedies for each individual is provided. None of the current service user group self medicates, consideration should be given, where appropriate to promote further independence in this area. In a sample of care files it was noted that service users and relatives had been asked if they had any specific wishes for arrangements in the event of the service users death. These conversations had come about as a result of the loss of service user in the last couple of years, and from relatives who had made family arrangements and wished them to be respected. While appreciating this is a difficult area for service users, staff and relatives, it was a positive observation from this inspection that the service had felt able to address the matter. 55 Drubbery Lane DS0000008245.V302449.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality outcome of these standards is good. This judgement was based on information received in the pre inspection feedback; from observation and discussion with service users during the inspection visit. Service users were supported to express their concerns, and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: No complaints or Vulnerable Adults concerns have been forwarded to the CSCI since the last inspection. The information in the pre inspection questionnaire stated that the service had not received any complaints and relatives questionnaires indicated that they were happy with the service. All service users had an independent advocate allocated to support them. The complaints procedure had been produced in a format that was user friendly and was displayed in the home. All comments received from families and other visitors to the home were positive. Service users said that if they were concerned they would go to their key worker or any of the staff. Throughout this visit there was evidence of good relationships between staff and service users, one service user stated that she trusted the staff to support her if she was concerned about anything. The manager confirmed that all staff had received training in Vulnerable Adults procedures, recognising and reporting Abuse. The service policy and procedure relating to these issues was available in the office of the home. 55 Drubbery Lane DS0000008245.V302449.R01.S.doc Version 5.2 Page 17 55 Drubbery Lane DS0000008245.V302449.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The quality outcome of these standards was good. This judgement was based upon observation but not a detailed scrutiny of the environment. EVIDENCE: The home is single storey building located in a service residential area of Blurton in Stoke-on-Trent. This visit did not included a detailed inspection of the environment, but the impression was of a well maintained comfortable home, where service users were able to exercise some choice over their living environment and personal space, restricted only by the equipment needed to ensure their safety and well being. The manager stated in the pre inspection information that new flooring had been put down in the lounge and bedrooms, the original carpeting had been replaced with a modern laminated flooring which had also was helpful to those service users who were independently mobile in their wheelchairs. Some general redecoration of the lounge and hallway had taken place since the last inspection. 55 Drubbery Lane DS0000008245.V302449.R01.S.doc Version 5.2 Page 19 The manager also discussed the proposals for the closure of the home, and the re location of service users. This matter has been discussed at previous inspections, it is concerning that service users and staff continue to be unsure about their future and it is hoped that a decision can be reached speedily which will take in to account and respect service user views. One service user showed me his room during this visit, it was clean comfortable, appropriately furnished, decorated and personalised. Communal space was provided in a lounge/dining room; appropriate adaptations were evident throughout. Easy access to the home and the garden area had been facilitated and all areas in the home were accessible to service users. Radiators in communal areas had excessively high surface temperatures, the manager was asked to ensure the safety and well being of service users by taken action to reduce the risk from them. This is a requirement of this report under the Conduct and Management section. 55 Drubbery Lane DS0000008245.V302449.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35,36. The quality outcome of this area was good. This judgement was based upon the evidence provided in the information and records seen; from discussion with staff, service users and the manager. EVIDENCE: The evidence from this inspection showed that staffing levels were high, 2 support workers were provided during the waking day from 7am-10pm. The shift pattern is 7am-2.30pm, 2.30pm-10pm. At night there is one waking and one sleep in staff. The weekly staffing establishment was reported to be 364 hours inclusive of 10 to take into account holidays and sickness, Actual hours were 311 per week according to this weeks rota, plus 6 hours domestic cover. The manager usually has supernumerary hours of 36 per week. Some agency staff were being used to ensure staffing levels were satisfactory to meet the needs of the service users. In the pre inspection information the manager stated that 7 of the 12 care staff had achieved NVQ level 2 or above, exceeding the minimum requirement of 50 of the workforce. The information provided during this visit indicated that some changes had taken place since receipt of the pre inspection info and that only 5 staff had this qualification. The manager stated that some staff had been nominated for the training for this year. 55 Drubbery Lane DS0000008245.V302449.R01.S.doc Version 5.2 Page 21 The service has appropriate recruitment and employment policies and procedures this was confirmed from the sample of records seen. Two members of the care team gave satisfactory accounts of their recruitment and employment experience and confirmed that they had staff meetings, supervision and training opportunities. There was some concern about the current on call management arrangements, during the site visit the manager who was off sick was contacted to discuss an area of concern. Staff identified some problems on occasions contacting the named on call manager and felt that the current arrangements were not always adequate. Staff should feel confident that should they require support from the on call service that contact can be made easily. 55 Drubbery Lane DS0000008245.V302449.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41,42 and 43. The quality outcome of these standards was good. This judgement was based upon an inspection of the relevant information available, discussion and observation. Further work is needs to ensure that fire drills are undertaken and service user are not at risk form the hot surface temperatures of radiators. EVIDENCE: Mrs Hawley was approved as the registered manager two years ago, and was at that time committed to working towards completion of her NVQ level 4 in care and Registered Care Managers Award. Mrs Hawley was asked to provide evidence that she that she had completed both qualifications. Areas of concern in this area included fire safety. The manager was asked to ensure that all staff were involved in regular fire drills at least two per year. They must receive fire safety training and the home must have fire safety risk assessments for individuals and have an emergency contingency plan in place. 55 Drubbery Lane DS0000008245.V302449.R01.S.doc Version 5.2 Page 23 These things were discussed and agreed at the feedback session with the manager. General and individual risk assessments were in place and reviewed regularly. The quality of the assessments and the action staff should take to reduce the risk to the individual was high. Risk assessments had been completed regarding the surface temperature of radiators. Each radiator in communal areas it fitted with a thermostatic control device, and the guidance in the risk assessments indicated that the thermostats should be set at a certain level, despite the evidence that the guidance was being followed, the surface temperatures of radiators during this visit was excessive. The manager was asked to ensure that action was taken to ensure service user safety, she addressed this during the day be turning thermostats down. Further action is required to ensure the on going safety of service users. It should be noted that radiators in service users bedrooms are covered. Policies and procedures were in place and complied with the required by regulation and good practice in this specialist area of care. There was evidence of reviews but some had not taken place for some time. The service should also give further consideration to translating some of the policies and procedures in more user friendly formats. Records of servicing of equipment showed that they were up to date, this included lifting equipment, and emergency call systems. The service had quality assurance systems in place and there was evidence provided that any action points from quality audits are acted upon and inform the annual development plan for the home. 55 Drubbery Lane DS0000008245.V302449.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 2 2 3 3 3 4 3 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 3 2 3 3 3 LIFESTYLES Standard No Score 11 x 12 2 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 1 3 55 Drubbery Lane DS0000008245.V302449.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes 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 YA11 Regulation 16(2)(n) Requirement The home must provide facilities for recreation including activities relating to recreation and training. (previous timescale not met 16/01/06). Service users must be protected form the risk presented from high surface temperatures of radiators. All staff must be involved in fire drills. Fire safety risk assessments must be completed for each service user, detailing the level of risk and the support they would require to evacuate the home in the event of a fire. Timescale for action 22/04/07 2 YA42 14(4)(a) 22/04/07 3 4 YA42 YA42 23(4)(e) 23(4)(c )(iii) 22/04/07 22/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 55 Drubbery Lane DS0000008245.V302449.R01.S.doc Version 5.2 Page 26 1. 2 3 4 5 6 YA20 YA40 YA36 YA33 YA7 YA24 Homely remedies list should be agreed with the GP for each individual. Further efforts should be made to produce relevant policies and procedures in a format that service users can easily understand. A review of the current on call arrangements should be considered to ensure that staff are confident in it. A review of the current deployment of staff should be considered in line with the comments made by a service user about reduced availability in the evening. The management arrangements for service users monies should be reviewed. Service users views regarding the future of the home should be considered and respected where possible. 55 Drubbery Lane DS0000008245.V302449.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 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 55 Drubbery Lane DS0000008245.V302449.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!