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Inspection on 15/11/06 for 55 Malvern Road

Also see our care home review for 55 Malvern Road for more information

This inspection was carried out on 15th November 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The care that is provided at the home revolves around the service users who live there. The complex needs of service users are understood and met in an appropriate way. The building and equipment is well maintained and the house is nicely decorated, and is also comfortable and clean. The commitment of staff in supporting and enabling service users to achieve as much as they are able is commended. A high standard of personal and health care is provided. The Organisation is clear about the support, training and development for the staff it employs, and staff confirmed that they have good training opportunities. The detailed information provided for service users is produced in an appropriate format, and is reviewed regularly. The families of service users are also supported and their involvement with the home is encouraged.

What has improved since the last inspection?

Further developments to the premises have been undertaken. The new equipment and sensory room provided recently has greatly enhanced facilities for service users. The quality of the service provided at the home is checked to make sure that the home achieves what it says it will for service users. Staffing levels have improved and the team is more settled, with benefit to both service users and staff. Medication procedures have been reviewed, and additional information provided for staff. Reviews of the medication prescribed for service users are undertaken regularly.

What the care home could do better:

Maintain a more detailed record of comments made about the service, specifically any compliments received, to give a more balanced view of what people think. Implement the recommendation of the Environmental Health Officer, to replace the kitchen chopping boards a little more promptly. Organise fire awareness training and fire drills regularly, to ensure that the safety of service users and staff is protected.

CARE HOME ADULTS 18-65 Malvern Road, 55 St John`s Worcester Worcestershire WR2 4LE Lead Inspector R McGorman Unannounced Inspection 15th November 2006 2:00 Malvern Road, 55 DS0000018662.V317902.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 Malvern Road, 55 DS0000018662.V317902.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. Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Malvern Road, 55 Address St John`s Worcester Worcestershire WR2 4LE 01905 421787 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) www.dimensions-uk.org Dimensions (UK) Ltd Ms Julie Joan Hodgetts Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is primarily for people with a learning disability but may also accommodate those with an additional physical disability. 15th November 2005 Date of last inspection Brief Description of the Service: 55, Malvern Road is registered to provide residential care for up to five adults who experience a learning disability, who may have a physical disability, and whose needs are complex and diverse. The range of fees varies between £1,100 & £1,250 per week. The premises is a large, detached property, situated in a pleasant residential area of St. Johns, approximately one mile from Worcester city centre, with easy access to public transport and a range of amenities and facilities. The home is owned and run by Dimensions (UK) Ltd., and is part of The New Dimensions Group, which, as the parent Company, provides strategic direction and a range of functional support services. The stated purpose of the organisation is, to work with people with learning difficulties, supporting them to make choices and to exercise control over their lives, and the main aim of the home is, to deliver a person-centred response to the needs and aspirations of the people we support. Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine key inspection was to monitor the care provided at the home, to assess how well the service meets the needs of the people who live there, and to follow up previous requirements and recommendations. The visit was unannounced and took approximately 3 hours, and part of this time was spent with service users, mostly observing their interactions with the people who support them, as they are unable themselves to verbally communicate their views. During conversations with staff, comments were made about what it is like to work at the home, and also to be employed by the organisation. Staff had assisted service users in completing a survey entitled, ‘Have Your Say,’ – which provides information about what they think about the care and support they receive. Written comments were requested from relatives, and views were also sought from visitors or professionals at the home during the inspection. The care records of service users were seen, and discussion held with the manager about the content. One was inspected in detail for case tracking purposes. A tour of the building was undertaken, and the records kept in respect of the maintenance of equipment, and safe working practices were also checked. The Care Manager, Ms Julie Hodgetts, was on duty during the inspection. She has many years experience in caring for service users with a learning disability, and is able to effectively provide support to service users and staff who live and work at the home. Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Further developments to the premises have been undertaken. The new equipment and sensory room provided recently has greatly enhanced facilities for service users. The quality of the service provided at the home is checked to make sure that the home achieves what it says it will for service users. Staffing levels have improved and the team is more settled, with benefit to both service users and staff. Medication procedures have been reviewed, and additional information provided for staff. Reviews of the medication prescribed for service users are undertaken regularly. Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 7 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. Malvern Road, 55 DS0000018662.V317902.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 Malvern Road, 55 DS0000018662.V317902.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): 2&4 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Appropriate documentation is in place to enable prospective service users to make an informed decision about their future care needs. The assessment process is both detailed and thorough, to ensure that appropriate decisions are made, both by the home and the service user. EVIDENCE: The Statement of Purpose and the Service Users Guide, provide detailed information for service users and their families, about the services and facilities available at the home. The documentation is produced in an appropriate format, and is being reviewed to ensure that it accurately reflects all aspects of the care provided. There have been no recent admissions to the home, although the process was discussed with the manager, who confirmed that it includes extensive assessment by staff from the home, and a Community Care Assessment undertaken by a social worker. Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service users plan of care is based on the initial assessment, which clearly identifies their assessed needs, and how these will be met. Service users living at the home are supported by their key workers in making choices in all areas of their lives. Service users are helped to take part safely in the various activities of daily living and to enjoy new opportunities. Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 11 EVIDENCE: Care planning procedures are well developed at the home, and are based on the initial assessment undertaken during the admission process. The details recorded in the documentation relating to each service user are discussed with them and their family, or a representative. The care plan of one service user was seen, and this was very comprehensive. The specific areas of need were identified, and details recorded as to how these were to be met. The information emphasised the positive aspects of the person, specifically, ‘what the service user likes’, and ‘what we like about the service user’. Another very informative entry was entitled, ‘Never/Ever’! The plan of care was divided into several parts and included an Essential Lifestyle Plan, a Support Plan, a Health Action Plan, and a Communication Passport. Together these covered every aspect of the life of the service user, included photographs and contained information about personal and financial details, daily routines, social and leisure activities, living skills, risk assessments The Person Centred Approach is part of the philosophy of the care provision at 55 Malvern Road, and participation in the daily life of the home is encouraged. The service users living at the home are not able to communicate verbally, and their needs are very complex, therefore, staff are continually striving to identify their individual preferences by interpreting their reactions to each situation. There was evidence in the care plans, of effective person centred care being delivered, and the positive interactions observed between staff and service users were pleasing to observe. One key worker and a co-key worker are assigned to each service user, and they have responsibility for ensuring that appropriate care is provided. Monthly meetings are held, on-going assessment is undertaken, changes are monitored over a period of time, and records amended when necessary. Risk assessments are completed, in relation to the premises, to the activities undertaken, and any restrictions imposed, and also in respect of every aspect of the life of each service user. The documentation relating to risk assessments is very detailed and well maintained, and was last reviewed in June 2006. Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 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 the focus of the delivery of the high standard of person centred care that is provided. Each service user takes part in various activities, both within and outside the home, and they are able to choose what they want to do and when. The opportunities made available to service users enable them to live as fulfilling a life as possible. There is a flexible approach to the provision of a healthy diet, and service users are encouraged to decide what to eat and when. Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 13 EVIDENCE: Service users living at the home are encouraged to follow an ‘ordinary’ life style as far as possible, by using the same facilities as other members of the community, and being involved in a range of leisure activities. The individual programme arranged for each service user acknowledges their preferences, their rights are respected and the daily routines revolve around their personal choice. Limited communication skills preclude involvement in paid employment or educational opportunities, although a tutor from the College works with service users at the home, doing music and arts and crafts. Social activities are provided, either in-house or in the community, and include, shopping, cookery sessions, swimming, visits to the snoezlan, jacuzzi, and hydro, and also to local garden centres, and attending discos. Day trips have been organized to various places including Weston-Super-Mare, the Elan Valley and the Safari Park, and visits to the pub and going out for a meal are also arranged regularly. One service user particularly likes going for a drive in the car, and this is a frequent occurrence. Staff organized a B.B.Q. in the summer to celebrate the 50th birthday of a service user, which was a great success. Another service user provided the house with a plentiful supply of tomatoes, which were produced in grow bags. Music making is very much enjoyed by some service users, and in-house entertainment is also arranged from time to time. One service user demonstrated his skills in playing the keyboard for the inspector. Links with family and friends are promoted, with a high degree of support provided by staff, to both the family and to the service user. The involvement of volunteers or an advocate is sought in the absence of family contact. The arrangements regarding the provision of food reflect the individual likes and dislikes of each service user. General food stocks for the home are purchased each week, with the assistance of service users. Meals are discussed, and although service users may not be able to express their specific requirements, it is made very clear if something is not wanted. There may be four different meals, all provided at various times, although lunch is a light snack and the main meal is usually taken in the evening. Healthy eating is encouraged, and a record is maintained of the food provided. Malvern Road, 55 DS0000018662.V317902.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 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The manner in which support is provided by staff ensures that the rights of service users are respected and their independence promoted, in meeting the personal and health care needs of each individual. The procedures for the administration of medication ensure that the health of service users is promoted, and that they are protected. The training provided for staff has increased their awareness in relation to the ageing process and possible illness and death of a service user Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 15 EVIDENCE: The personal care needs of service users are well documented, and there is evidence to show how staff understand and respond to them in an appropriate way. The healthcare of service users is closely monitored, and additional specialist support and advice is sought from the primary health care team, and other health professionals, when necessary. Optical care is arranged as necessary, and dental treatment is also provided, although staff usually attend to the nails of service users. Health Action Plans have been implemented for all service users. Each person living in the home receives the individual health care they need. Service users health is reviewed regularly and referrals made to a specialist whenever necessary, which maybe regarding their mobility, or eyesight or for a chronic medical condition. They are supported by staff to attend hospital outpatient appointments or for treatment. Medication arrangements at the home are satisfactory. A Monitored Dosage System is in use, and regular checks by the pharmacist are undertaken. The Medication Administration Records had been completed appropriately, and a detailed profile, together with a photograph was completed for each service user. All staff take a Medication Competency test at regular intervals. Staff confirmed that they had undertaken training on death and bereavement, in order to increase their awareness of these issues, and to enable them to deal sensitively with the possible terminal care or death of a service user. Malvern Road, 55 DS0000018662.V317902.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are able to express any concerns, through an effective complaints procedure. Staff know what they should do to protect service users from all forms of abuse. EVIDENCE: A clear procedure for the investigation of complaints has been produced and any issues are dealt with immediately. The document has been produced in a format that is understandable to service users. There have been no complaints since the last inspection. The need for all comments, concerns and compliments to also be recorded was discussed with the manager. An appropriate procedure is in place relating to the many aspects of abuse and the protection of vulnerable adults, and training is provided for staff. Staff showed a clear understanding of the issues, and also to their individual role as an advocate for service users. Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 17 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, 28 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The location of the house is convenient to local services and facilities, and the layout provides adequate communal space for the needs of service users. The premises are suitable for their purpose and the accommodation is maintained to a satisfactory standard, providing service users with a comfortable and homely place to live. The premises are clean and hygienic, and ensure as far as possible that the safety and wellbeing of service users is promoted. The safety of service users may be compromised if fire awareness training is not undertaken with the required frequency. Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 18 EVIDENCE: The premises at 55, Malvern Road is a large detached house with accommodation on two floors, which is maintained to a satisfactory standard, and is suitable for its purpose. There have been several developments recently that have resulted in improvements in facilities for service users. The communal areas of the house are homely, nicely decorated and comfortably furnished. The gardens to the rear of the property are mostly lawned, and they are accessible to service users. There was evidence of work having been undertaken to maintain them, although they were looking very autumnal under a carpet of leaves on the day of the inspection. A ground floor bedroom opens on to part of the patio through French windows. Decking has been laid and a small area fenced off, and several flower tubs, hanging baskets and sensory items have created a lovely secluded arbour for the service user. There are three communal rooms, which include a pleasant lounge, a dining room and a recently developed sensory room. Sensory equipment has always been provided at the home, but a room on the first floor, previously used as an office, has been fitted with various items of equipment, including a keyboard, and can be accessed by service users at any time. Several items of equipment have been replaced, and these include the microwave, the dishwasher, the tumble drier and an iron. Safe boxes have been fitted in the bedrooms. New carpets are to be laid in two bedrooms. The home is clean and fresh, staff are familiar with the procedures regarding the control of infection, and they have had training in health and safety matters. There is one outstanding requirement following a recent visit from the Environmental Health Officer. New colour coded chopping boards are to be provided, and the manager has been making enquiries with suppliers for the most cost effective purchase, although this has taken some time, and now needs to be resolved. Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 19 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): 33, 34 & 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has an experienced and competent team of staff, who are able to ensure that the needs of service users living at the home can be effectively met. Appropriate recruitment procedures ensure that service users are supported and protected by staff. The extensive training programme available to staff ensures that they are competent in their work, and therefore able to provide appropriate care and support to service users. Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 20 EVIDENCE: Dimensions provides relevant information for staff on joining the organisation, and also keeps them updated on new developments and any changes that take place. Each member of staff is given a Welcome Pack that contains details about the organisation, and its aims and objectives, an Employee Handbook that provides information about terms and conditions of employment and policies and procedures, and an Induction Checklist covering the first three months of employment. Staffing arrangements at the home are now quite stable. Several staff have returned from maternity leave, and some new employees have also been recruited. Waking night staff are employed, and service users benefit from the commitment and support they receive. A thorough recruitment and selection procedure has been produced by the organisation, and includes a commitment to equal opportunities. Criminal Record Bureau checks are completed prior to an appointment being confirmed, and verbal and written references are also obtained. A training programme is in place at the home that includes statutory and specialist care related training. Induction and Foundation training, (known as ‘Welcome to Our Team’), and the Learning Disability Award Framework (LDAF) accredited training are available to staff. The training needs of staff are regularly reviewed, and a training record is maintained in respect of each member of staff. Confirmation was provided during discussions with staff about the opportunities for training, and the courses they had attended recently, and included MAPPA, Epilepsy, Listening and Enabling, Death and Bereavement, and Leadership training, in addition to the mandatory courses, which are routinely undertaken. Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management arrangements at 55, Malvern Road, enable service users and staff to benefit from a well run home. The rights of service users are safeguarded by the effective policies and procedures, together with appropriate records that are maintained at the home. The health, safety and welfare of service users and staff is promoted and protected in respect of all safe working practices Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Care Manager, Ms Julie Hodgetts has achieved the Registered Managers Award and the NVQ Level 4 qualification in care. She is also a NVQ Assessor. The manager has many years experience in caring for service users with a learning disability, and is able to effectively provide support to service users and staff, who live and work at the home. She has good communication skills, and a clear understanding of her role and responsibilities. An annual development ‘PATH’ plan has been produced which involves the whole home, and forms part of the quality assurance programme for the Organisation. The team identifies where they are at, where they want to be in 12 months time, who they need to help them to get there, the building bricks and the strengths required, and who does what. Reviews of achievements take place every 3 months, and the outcomes are measured. The Quality Monitoring Officer visits the home on a regular basis, and undertakes an audit of the various systems, some of which are being standardised following the addition of several new homes to the group. Policies and procedures are produced by the Organisation, and staff confirmed they are familiar with the content. Specifically, an extensive health and safety policy and procedure is in place, and the Company employs an officer to advise on health and safety matters. Risk assessments in respect of all safe working practices are completed. The Fire Log Book was seen, and the appropriate checks have been undertaken with the required frequency. The Fire Risk assessment was reviewed in June 2006. Fire awareness training is undertaken, but not regularly every three months. The manager was also reminded of the need to ensure that a fire drill is organised every six months and a full evacuation annually. The records checked during the inspection have been completed to a satisfactory standard. Regular maintenance and servicing of equipment is undertaken routinely, and temperature checks are recorded. The accident records were seen to be in order. Notifications are made under Regulation 37, which requires reports to be sent to the Commission of death, illness or other events in the home. Regulation 26 reports, which relate to visits made to the home by or on behalf of the registered provider, are also submitted on a regular basis. Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 X 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 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 2 X Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 24 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 2 3 Refer to Standard YA22 YA30 YA42 Good Practice Recommendations All comments, concerns and compliments made about the service should be recorded The recommendations of the Environmental Health Officer should be implemented without delay Fire awareness, drills and practices should be undertaken with the recommended frequency Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Malvern Road, 55 DS0000018662.V317902.R01.S.doc Version 5.2 Page 26 - 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!