Inspection on 21/11/06 for 56 Oakwood Road

This inspection was carried out on 21st 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 found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

56 Oakwood Road 01/12/05

56 Oakwood Road 09/06/05

56 Oakwood Road 29/09/04

56 Oakwood Road 19/04/04

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

CARE HOME ADULTS 18-65 Oakwood Road (56) 56 Oakwood Road Horley Surrey RH6 7BU Lead Inspector Joseph Croft Key Unannounced Inspection 21st November 2006 10:30 Oakwood Road (56) DS0000013521.V320508.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 Oakwood Road (56) DS0000013521.V320508.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. Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakwood Road (56) Address 56 Oakwood Road Horley Surrey RH6 7BU 01293 775132 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) The Avenues Trust Limited To be confirmed Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 39 65 YEARS 1st December 2005 Date of last inspection Brief Description of the Service: 56 Oakwood Road is a care home providing personal care for six adults with learning disabilities. Currently the user group is all male. The Avenues Trust operating this home is an organisation providing care establishments for adults with learning disabilities in Surrey and Kent. The house is a detached, two storey property which is domestic in style and character. It has off street parking to the front of the building. There is a large, enclosed garden to the rear of the building with summer - house and garden furniture. The home is located in a residential area, close to Horley town centre and is convenient for public transport and all community facilities. Bedroom accommodation is all single occupancy, situated on the first floor, accessible by stairs only. The bedrooms are of a good size and have been decorated and personalised to reflect the taste and interests of occupants. Two large bathrooms and a quiet sitting area are also provided on the first floor. Communal areas on the ground floor comprise of a fitted kitchen, separate utility/laundry room and large, open plan combined dining / sitting room. An office facility is also located on the ground floor. Service provision includes a seven - person ‘people carrier’ model vehicle for the sole use of the home. The weekly fees range from £1199 to £1287. Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first Key Inspection using the Inspection for Better Lives process for the year 2006/2007. This key inspection ensured that all the core standards of the National Minimum Standards for Younger Adults were considered. This inspection was unannounced therefore staff and residents were not informed in advance of the inspection being carried out. This inspection was conducted by Mr J Croft on the 21st November 2006, and took seven hours, commencing at 10:30 hours and concluding at 17:30 hours. The inspection process included a tour of the premises, sampling of residents’ care plans, risk assessments, staff training records and records of staff recruitment. Other documents sampled included policies and procedures, staff duty rota, menu and records of medicines. Discussions took place with the acting manager and staff. The inspector saw all six residents. Due to the degree of learning disability and communication needs of residents living in this home it was not possible to obtain their views about the home or their care. Observations of staff interaction with residents were observed during the inspection. There are currently six residents living at the home. Discussions took place with staff on duty at the time of the inspection. Staff were knowledgeable about residents’ care plans, their likes and dislikes, and how to support them. Five requirements have been made during this inspection. Feedback was provided at the end of the inspection to the manager. The inspector would like to thank the staff and residents for their cooperation during the inspection. What the service does well: Assessment documentation, care plans and risk assessments are in place to ensure the needs of the residents are met. Residents are offered a healthy balanced diet. Residents are protected by the home’s safe administration of medicines. The home has a complaints system to enable residents and their families to raise concerns. Residents are protected by staff having knowledge and understanding of adult protection issues. The safety of residents is Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 6 promoted and safeguarded through appropriate health and safety procedures being in place. 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. Oakwood Road (56) DS0000013521.V320508.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 Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessment documentation is in place to ensure the individual needs of residents can be met. EVIDENCE: The acting manager stated residents have been living at the since it opened nine years ago and, as explained at the previous inspection, no assessments were undertaken prior to residents transfer from long stay hospital. However, the home had undertaken an assessment of residents’ needs, which was evidenced in the care file sampled. Information included self-care, household tasks, community, physical needs, mobility, communication, social skills, hearing/sight, sleeping, health needs and family contact. Due to the degree of learning disability and communication needs, the resident whose care file was sampled was not able to communicate with the inspector. The home uses The Avenues Trust Admission and Discharge Procedure dated 8th February 2005. This document gives clear information on the process to be followed for new admissions. This document states that only residents whose needs can be met will be admitted to the home. Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 9 The acting manager stated that for new admissions assessments would be sought from the referring care manager, and the manager and service manager from The Avenues Trust would undertake an assessment at the prospective residents current placement. Residents would be invited for day visits and overnight stays prior to moving in. The home does not admit emergency admissions. Oakwood Road (56) DS0000013521.V320508.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has care plans and risk assessments in place that ensures the needs of the residents are met. Residents are supported by staff to lead active lives. EVIDENCE: On the day of the inspection the care documentation sampled was up to date and in good order. Care plans included information in regard to residents’ personal care, communication, choice, behaviour management, medication, and activities. The home uses the key worker system whereby care staff work closely with one or two residents, enabling their assessed needs to be met. There was clear information on how to support residents with their personal care needs. During discussions, staff were able to give an account of the content of care plans for the residents with whom they key work, and were aware of the need to review care plans. Staff stated they support residents to make choices Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 11 about themselves, the clothes they wish to wear, food they would like to eat and daily activities. Records of decisions and activities attended by residents are maintained in their care plans and the daily records kept by the home. Residents do not have verbal communication, however, they are able to inform staff of their wishes through body language, gesticulation and leading staff by their hand. This was observed throughout the day of the inspection. Risk assessments were observed in care records sampled. They were regularly reviewed and used picture symbols to help residents understand the meaning of the documents. Residents have individual bank accounts, and the home holds small amounts of money for each resident. Monies sampled on the day of the inspection were appropriately maintained. The home uses security tags on individual moneybags. The acting manager stated residents’ monies are checked at staff handover time. This was observed during this inspection. Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with opportunities to improve their lifestyle and are offered a healthy balanced diet. EVIDENCE: The acting manager stated that due to their complex needs, no resident is in any form of paid employment. Residents take part in many activities such as recycling, shopping with staff support in the local town, attending day centres, line dancing and horse and cart sessions. On the day of the inspection residents were observed enjoying an aromatherapy session with the visiting aromatherapist. The home had a weekly activity programme, and maintains records of all activities undertaken by residents in their care plans and daily records. Risk assessments were in place in regard to activities. Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 13 Information from the pre-inspection questionnaire informs that residents also attend external activities such as music, art, swimming, line dancing, day centres and horse and cart sessions. During discussions, staff stated residents require support during activities, and go the shops with a one to one support. Each resident has a cultural needs assessment in his care file. This includes information in regard to family contacts, language, communication and records of religious festivals celebrated are maintained. Residents could attend church services of their choosing, records of which are maintained in their care plans and daily logs. During discussions staff stated they had attended training in regard to Equality and Diversity. The acting manager and staff stated family and friends are always welcome to visit the home, and that they always visit for birthdays and Christmas. The daily routines in the house are clearly recorded in care plans. Residents help as much as they are able with the chores around the house. Residents were observed to have access to all communal parts of the home, which includes a large dining room/lounge area, garden with a summerhouse and access to the kitchen with staff support. During discussions staff stated residents are treated as individuals; using first names, always knocking on bedroom doors, and supporting residents with telephone calls. During the inspection staff were observed interacting with residents in a caring manner, and respecting residents needs to have time on their own. The home uses a six-week menu that was viewed by the inspector. This provided evidence that balanced meals are offered which include meat, fish, pasta and fresh vegetables. Fresh fruit was observed to available to residents. Residents are able to make choices in regard to the menu through the use of photographs of meals. Food was found to be appropriately stored in the kitchen area, and records of fridge/freezer and cooking temperatures were evidenced. The acting manager stated that no current residents have any specialist dietary requirements. Care staff undertake the cooking duties. Evidence of training in food handling and hygiene was observed in staff training files sampled. During discussions staff stated that, in their opinion, the food residents receive is always good and balanced with meat and fresh vegetables. Lunchtime was relaxed and unrushed, with staff offering support to residents as and when required. Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 14 Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Physical and emotional health care is offered in such a way as to promote residents independence. Residents are protected by the home’s safe administration of medicines. EVIDENCE: During discussions, the acting manager and staff stated that residents require some support with their personal care. Personal support is recorded in care plans, and includes information of how the resident likes to be supported. Staff stated that key workers provide personal support in the privacy of resident’s bedrooms and/or bathrooms. Bedtimes are flexible, and residents are able to choose when they want to go to bed. The acting manager stated residents are offered the opportunity to lie in at weekends. The care plan sampled provided evidence that the arrangements regarding areas of health care are recorded. Records of visits to the GP, and attendance to the Dentist, Opticians, and other health care professionals are also Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 16 maintained. Residents have access to all NHS healthcare facilities as required. Incidents of illness are recorded in daily records and healthcare plans. The acting manager stated all residents have annual health checks. Evidence of visits by the Epilepsy nurse, monthly weight checks and hearing tests were evidenced. Staff had training in epilepsy and some staff had undertaken training in nutrition needs. Staff stated they are aware of the health care needs of residents, and support them when attending the GP and other medical appointments. The home uses the blister packs and Medication Administration Records sheets (MAR) for recording medication. Medical records sampled provided evidence that accurate records of medicines dispensed are clearly maintained. The home maintains records of medicines returned to the Pharmacist. Evidence was seen that the local Pharmacist had last visited the home in November 2005. The acting manager stated that telephone contact is maintained with the Pharmacist for any advice required. The home follows The Avenues Trust Medical Policy and Procedure. The manager stated only appropriately trained staff administers medication, and staff have an annual assessment review of their competencies. Training files sampled confirmed this. No current resident self medicates or is taking a prescribed controlled drug. Any known allergies are maintained in residents’ medication files. During discussions, staff stated they monitor and report any health concerns promptly to the GP. Staff stated they had read the home’s medical policy and procedure. Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints system to enable residents and their families to raise concerns. Residents are protected by staff having knowledge and understanding of adult protection issues. EVIDENCE: The organisation had a complaint procedure that had been produced in various formats including a pictorial format and a CD. Each resident has a copy of the pictorial version of the complaints procedure. Staff stated they are able to tell if residents are unhappy by their body language, and that residents will find a way of communicating their moods to staff. The complaints book maintained by the home evidenced there had not been any complaints received. Staff at the home follows The Avenues Trust Protection of Vulnerable Adults Policies and Procedures, dated 14/2/06, and the Whistle blowing policy, dated 1/10/04. Staff were able to give an accurate account of the procedure to be followed in the event of Protection of Vulnerable Adults issues. Staff stated they would not hesitate in reporting bad practice to the acting manager or the service manager. Evidence was viewed that all staff had undertaken training in the Protection of Vulnerable Adults. The acting manager and one senior care staff member had attended the Surrey Multi-Agency Protection of Vulnerable Adults training on the 12th October 2005. Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 18 There are procedures and policies in place with regard to service users finances. All individuals require some assistance in managing their money. Service users have individual accounts, and there is a system in place for where by small amounts of money are held and securely stored. Checks of the balance held for each individual money are made at each change of shift by two staff, who sign that they have completed this. An additional monthly check of account balances is undertaken by the organisation, with the home supplying all transactions undertaken in the previous month with receipts. Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides adequate communal and individual living space making it a comfortable place to live, however, identified areas require attention. EVIDENCE: The house is owned by a housing organisation. A tour of the premises was undertaken. The home was clean and tidy and the communal areas and bedrooms were brightly decorated. The service manager stated that the floor covering in the dining room and lounge area are due to be replaced once the quotes have been received by The Avenues Trust. The general ambience of this home is good, however, the following issues were identified, and the housing organisation must work with The Avenues Trust to resolve them. The two bathrooms on the first floor both had a malodour, which the service manager stated could be due to a previous water leak. An immediate Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 20 requirement was made in regard to this. It was noted that the bath panels were in need of redecoration or replacing and the water pipes were exposed. Requirements in regard to these have been made. The kitchen is in need of attention to the décor, cupboards, drawers, ceiling and cupboard doors. On the day of the inspection one wall mounted cupboard door in the kitchen was dangerously loose at the hinges. An immediate requirement was made in regard to this. The cupboard doors in the kitchen do not close properly, the bases of drawers were observed to be bowing, one kitchen worktop was not appropriately sealed, and the surface was damaged. The kitchen ceiling is in need of redecorating again, as watermarks are still noticeable. The care office has suffered water damage to one wall and the carpet must be replaced due staining from water. A requirement has been made that the registered provider must forward to the Commission For Social Care Inspection Surrey Local Office an action plan with time scales of how the identified issues to the kitchen and care office are to be attended to. Bedrooms were appropriately furnished and residents had their personal belongings. It was observed that bedrooms and bathrooms had unbreakable mirrors fixed to the walls. The home has a large garden to the rear of the property, and has a summerhouse with comfortable seating and games. There is a patio and garden furniture for residents to use in the appropriate weather. Staff at the home follow The Avenues Trust Infection Control policy. Staff stated they use plastic aprons and gloves when attending to personal care needs. At the time of writing this report, The Avenues Trust had forwarded details of how the immediate requirements were complied with. Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are satisfactory, ensuring staff have the qualities and training to meet the needs of residents. EVIDENCE: The acting manager informed the inspector that there are five staff that have been working at the home since it opened nine years ago. The home has a full compliment of 9 full time and two part time staff. The duty rota was viewed and evidenced a minimum of three members of staff on duty each shift. Staffing at the home includes the manager, two seniors, 6 care workers and 2 part time workers. The acting manager stated all staff are able to lead a shift. The acting manager stated new staff undergo an induction-training programme; these were evidenced in staff files. The home has two members of staff who have completed NVQ level 2, two staff are undergoing the NVQ level 3, and the acting manager has completed her NVQ in management and the Registered Managers Award (RMA). This means that the home is on course to achieve 50 of care staff to be NVQ qualified. Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 22 The Avenues Trust maintains recruitment files at their head office; this was in agreement with the Commission For Social Care Inspection Provider Relations Manager. The policy is that each care home maintains a tick sheet forwarded from head office that indicates application forms, four references, gaps in employment, Criminal Record Bureau numbers and proof of identity have all been seen by The Avenues Trust Human Resources team. This was confirmed during discussion with the service manager who was present for part of the inspection. Evidence of Criminal Record Bureau reference numbers were evidenced for six members of staff. The Avenues Trust has a rolling training programme, from May 2006 to April 2007. Staff training and development assessments were examined. Evidence was found of relevant induction and statutory training for all staff. Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for management and administration ensure the home is run in the best interests of residents, and the safety of residents is promoted and safeguarded. EVIDENCE: The acting manager has been in post since 18th September 2006, and has many years experience working in care homes for adults with learning difficulties, of which the last six years have been at senior level. Certificates evidenced the completion of the NVQ 4 in management 11/2/04, and the Registered Managers Award 24/2/05. The acting manager is applying for registration, and has an appointment to attend the Commission For Social Care Inspection Surrey Local Office on 23/11/06 to have Criminal Record Bureau countersigned. Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 24 The home has quality assurance monitoring systems in place. Monthly regulation 26 visits are conducted; the report for the October visit was viewed. There was evidence of minutes taken at monthly staff meetings. The acting manager informed the inspector that due to the low levels and complex needs of the residents it is not possible to have residents meetings. Annual surveys are undertaken to ascertain the views of families, relatives, and other professional visitors. A summary of the survey undertaken on the 22nd July 2006 was viewed. The contents of the returned questionnaires indicated satisfaction with standards of care at the home. Staff training files evidenced that The Avenues Trust provides mandatory and other professional training. The health and safety adviser conducts annual Health and Safety audits, and the nominated support worker undertakes monthly checks. Policies, procedures and systems were in place to ensure safe working practices. Risk assessments were carried out and recorded for all safe working practice topics. Fire risk assessments were in place for the home that included the office, living room, kitchen, laundry, bedrooms, hallway and bathrooms. These were reviewed on the 3rd July 2006. Arrangements for service contracts and repairs were in place to ensure the maintenance of a safe environment. Records sampled included all fire records, fire equipment manufacturers check, gas service records and portable electrical appliance testing was last undertaken on the 19th May 2006. Oakwood Road (56) DS0000013521.V320508.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 2 28 2 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 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 X 3 X 3 X X 3 X Oakwood Road (56) DS0000013521.V320508.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. 1. Standard YA27 Regulation 16 (2) (k) Requirement The registered provider must ensure the malodour in both bathrooms on the first floor is resolved. The registered provider must ensure the exposed water pipes in the identified bathrooms are made safe. The registered provider must ensure the bath panels are redecorated or replaced. The registered provider must forward to the Commission For Social Care Inspection Surrey Local Office an action plan with time scales of how the identified issues to the kitchen and care office are to be attended to. The registered provider must ensure the identified wall mounted cupboard door is replaced or repaired. Timescale for action 21/11/06 2. YA27 13 (4) (c) 28/12/06 3. 4. YA27 13 (4) (c) 13 (4) (a) (b) (c) 28/12/06 14/12/06 YA24 5. YA28 13 (4) (c) 21/11/06 Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 27 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 Oakwood Road (56) DS0000013521.V320508.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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