Inspection on 07/08/07 for 63 Hoveringham Drive

This inspection was carried out on 7th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

63 Hoveringham Drive 14/07/09

63 Hoveringham Drive 12/12/06

63 Hoveringham Drive 10/01/06

63 Hoveringham Drive 03/05/05

63 Hoveringham Drive 06/12/04

63 Hoveringham Drive 16/08/04

Similar services:

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Polesworth Group Friary Road

Polesworth Group Pooley Heights

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

CARE HOME ADULTS 18-65 63 Hoveringham Drive Eaton Park Stoke-on-Trent Staffordshire ST2 9PS Lead Inspector Pam Grace Key Unannounced Inspection 7th August 2007 10:00 63 Hoveringham Drive DS0000008319.V345175.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 63 Hoveringham Drive DS0000008319.V345175.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. 63 Hoveringham Drive DS0000008319.V345175.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 63 Hoveringham Drive Address Eaton Park Stoke-on-Trent Staffordshire ST2 9PS 01782 201766 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) Hoveringham@choiceshousing.co.uk Choices Housing Association Limited Mrs Terri Byczkowski Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6), Physical disability (6), of places Physical disability over 65 years of age (6) 63 Hoveringham Drive DS0000008319.V345175.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents with either Learning Disability (LD or LD(E) category may also have a Physical Disability (PD or PD(E) 12th December 2006 Date of last inspection Brief Description of the Service: Hoveringham Drive is located on a large private housing estate in the Bucknall area of Stoke-on-Trent. It has access to a small but adequate shopping centre and, via a local bus route, has relatively easy access to the main shopping centres of Hanley and Longton. The bungalow is a purpose built unit that is run by The Choices organisation, who have a number of similar homes throughout the Potteries area. This home is registered to provide care for six [currently female] residents with varying degrees of Learning Disability. Two current residents have physical incapacity. The design of the home is based on the domestic model, with six bedrooms, a domestic kitchen/diner, laundry, and a communal lounge. Bathrooms and toilets have been specially adapted to assist those residents with a physical disability. Doorways and corridors are wide to facilitate wheelchair use and have been fitted with grab rails. The open plan layout established by creating an archway between the kitchen and the lounge has achieved its objective of encouraging residents to make more use of the lounge facilities. The property has a small but well kept garden at the rear with adequate seating for use in fine weather. There is a sloping Tarmac covered area at the front for car parking The exterior and interior are in a good structural state of repair. Current fees range from £211.55 to £456.13 per week. Fees are subject to annual review and do not include items such as hairdressing and personal toiletries. 63 Hoveringham Drive DS0000008319.V345175.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out over the afternoon of Tuesday the 7th of August 2007. The registered care manager was in attendance for part of the inspection. Feedback was later given to the care manager in relation to the inspector’s findings. The home was clean, warm, tidy, and well maintained throughout. Staff were observed giving positive and appropriate regard to residents during their interactions. Staff spoken with, were very knowledgeable about residents’ needs and wishes. Care plans examined, demonstrated a clear understanding of the social, physical, and psychological needs of individual residents, together with appropriate person centred and planned intervention to assist them in maintaining their well-being and lifestyle. There were no requirements and or recommendations made as a result of this inspection, and the home’s care manager and staff are commended for the extremely high level of quality of care given by staff towards residents at the home. What the service does well: What has improved since the last inspection? 63 Hoveringham Drive DS0000008319.V345175.R01.S.doc Version 5.2 Page 6 Fire Prevention works had been undertaken, and compliance advice sought. New fire doors had been fitted, and a review of emergency evacuation procedures had been undertaken with all staff members to allow for this. The Fire Officer has endorsed that the home complies with Fire Regulations. A new security light, and level paving had been fitted to the rear evacuation route from the home. Carbon monoxide monitors had been installed Completed individual personal emergency evacuation plans for each resident. Regular staff training has been provided reflecting these changes. Dental health checks have been established for residents. A pictorial complaints procedure has been implemented, and given to, or explained to residents and their relatives. 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. 63 Hoveringham Drive DS0000008319.V345175.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 63 Hoveringham Drive DS0000008319.V345175.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people who use this service and their representatives have the information needed to choose a home, which will meet their needs. They have their needs assessed and a contract which clearly tells them about the service they will receive. EVIDENCE: The recently updated and pictorial Statement of Purpose was examined, it clearly sets out the aims and objectives of the home. The Service User Guide was in the process of being reviewed and will be available in pictorial format very soon. Care records seen were clear, comprehensive, person-centred and up to date. They showed that a full pre-admission assessment had been undertaken. The assessment is then used to inform the care plan, which covers all aspects of social and health care planning. Care planning included the following : * Recognition of residents’ rights, freedoms, needs and choices. * Active support, both within the home and as part of the local community. * Recognition of residents’ individuality and diversity. * Regular reviews, evaluation, monitoring and updating of care and support. * Systems were in place to access other professional agencies to enhance care 63 Hoveringham Drive DS0000008319.V345175.R01.S.doc Version 5.2 Page 9 and support. * Appropriate risk assessments. Discussion with staff in regard to pre-admission visits, confirmed that residents and or their relatives or representatives, can and do visit the home prior to making a decision to move in. The care manager and staff confirmed that each resident has a contract, or terms and conditions of service for the home. 63 Hoveringham Drive DS0000008319.V345175.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 excellent. This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: 4 care plans were examined in detail. All evidenced that choice and preferences are taken into consideration for individual residents at the home. Care plans seen were up to date, and very comprehensively completed. Daily records were also up to date and clear. Health and Social care needs were identified, and care planning included appropriate and clear risk assessments. Care plans evidenced that health professionals were involved, and health needs met. Staff spoken with confirmed that wherever possible residents were included in any choices that were made in relation to how they were cared for, and that 63 Hoveringham Drive DS0000008319.V345175.R01.S.doc Version 5.2 Page 11 they were supported to maximise their independence, and to minimise their dependence on other people in their daily lives. The input of the dietician was noted in care plans seen, with appropriate advice given in relation to weight management. Residents were spoken with, and from these informal discussions the inspector confirmed that they were involved in decision-making, for example decisions such as what to wear, how to dress, where to shop, what to eat, what to drink. Interactions between staff and residents were observed during the course of the inspection visit. Staff appropriately addressed residents, and supported their every need, in a sensitive, valuing and respectful manner. Staff spoken with confirmed that they know the residents needs extremely well. Residents appeared well cared for and very happy in their surroundings. 63 Hoveringham Drive DS0000008319.V345175.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 excellent. This judgement has been made using available evidence including a visit to this service. People who use these services are able to make choices about their life style, and are supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s needs. EVIDENCE: Residents at the home have a number of community and social links, and are fortunate in being located near to a large care complex (Berryhill) where the residents can go for fellowship and activities. When the inspector arrived in the home, one resident had been out shopping (locally) and another resident had just returned from a session of Armchair Aerobics – both residents were supported by staff members. Discussion with staff and residents, and reference to care plans showed that a wide variety of friendships and relationships were maintained, including friendships with residents in other homes. Interhome visiting was a feature of 63 Hoveringham Drive DS0000008319.V345175.R01.S.doc Version 5.2 Page 13 these relationships, both on an individual and a group level, as were letters and phone calls to and from family members. Residents’ holidays are organised each year, and residents also go on theatre trips, lunches, shopping trips and Fellowship meetings. Visits to the hairdresser are regularly undertaken by residents, this is done on an individual basis, and residents can choose which hairdresser they want to go to. The home has a minibus which is shared by the sister home, and is used for health appointments. The inspector was pleased to note that some residents at the home have a “Life Book”, these are books that contain memorabilia from trips out, photographs, entrance tickets, leaflets etc…. reminding the resident of where they’ve been and what they’ve done, for example birthdays and special occasions. The inspector was shown a Life Book belonging to one of the residents, this was very sensitively put together by the keyworker, with the assistance of the resident wherever possible. Residents help with routine tasks around the home in line with their abilities, and according to their risk assessments. Staff reported that residents do sometimes assist with meals in the kitchen, lay the table, clear dishes away, and help with the food shopping. Records showed that as well as eating in the home, residents regularly access the community for pub lunches, and this is usually done on a one-to-one basis supported by their key worker, rather than in an easily identifiable [and therefore stigmatised] institutional group. During the late afternoon staff were preparing the evening meal which was cottage pie and vegetables. Menus and records of meals actually served demonstrated a good variety including seasonal and local choices, and the likes and dislikes of residents in relation to food, had been recorded in their care plans. The kitchen area was domestic in size and layout, and easily accessible for residents and staff use. 63 Hoveringham Drive DS0000008319.V345175.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 and 21 - Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: All current care staff working at the home are female, as are all current residents. There were no issues raised in relation to choice of staff from the same gender. Aids and adaptations were provided to improve the safety of individual residents where appropriate. During the course of the day staff were observed to work sensitively to maintain the dignity of residents in terms of their personal hygiene, and to assist them with any personal care tasks in privacy. The healthcare modules of those care plans examined demonstrated the extent to which staff worked to try and maintain the well-being of the residents of the home. All residents are monitored by staff for any changes in either their health, or their mental health. All staff had undertaken a threeday training course in the Management of Actual and Potential aggression. 63 Hoveringham Drive DS0000008319.V345175.R01.S.doc Version 5.2 Page 15 Records evidenced that regular checks had been initiated by the provider on the basis of good practice recommended in the British Institute for Learning Disability key values 24-hour support plans behavioural risk assessments and appropriate and regular reviews of the status of the individuals health including tissue viability, blood pressure monitoring, and nutritional screening, and regular individual reviews of medication. Records also evidenced that appointments and letters in regard to health needs were being met, these included individual healthcare clinicians, Consultants, GPs, district and specialist nurses, clinics and Health Centres. Residents would be supported by their key worker, and transport would be provided by the mini bus. Residents also have access to dentistry, chiropody, ophthalmology and audio clinicians. The local GP surgery has a Well Woman annual health check system in place, which some residents had attended. Medication Administration Records were appropriately signed, and supplies of medication were appropriately managed and documented. 63 Hoveringham Drive DS0000008319.V345175.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 and 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 their concerns, and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: During discussion with the care manager it was established that all staff receive refresher training on the protection of vulnerable adults every three years. The abuse policy, i.e. Protection of vulnerable adult (POVA) policies are read with a proportion of the staff once every two months, so that each year everybody will have signed to say that they have really read and understood these policies. The care manager, and the Commission for Social Care Inspection had not received any complaints or POVA referrals since the previous inspection. During the afternoon two staff interviews were undertaken. Staff spoken with confirmed that they were aware of the vulnerability of the residents, and the need to protect vulnerable adults. They also confirmed their knowledge of the different types of abuse, showing a clear understanding and commitment to protecting residents. CRB/POVA Police checks were confirmed in relation to staff recruitment. 63 Hoveringham Drive DS0000008319.V345175.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): 24,25,26,27,28,29 and 30 - Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The inspector undertook a tour of the building. The home is purpose built, and the standard of maintenance is very high. The lounge was particularly good, with a comfortable big leather sofa and chairs, television, and very homely atmosphere. The exterior of the building was in a good state of decoration, and maintenance. The grounds were wellkept, clean and tidy. The route from the rear fire exit has been improved, and widened to ensure the safe exiting of the building by residents, if there is a fire/alarm test. A 63 Hoveringham Drive DS0000008319.V345175.R01.S.doc Version 5.2 Page 18 security light is used at night, to make the area safer to use after dark. Two sets of Fire doors have been installed in compliance with Fire regulations. The home has been purpose built, and has been constructed in similar brick to the rest of the estate on which it stands, this does not stigmatise the home in any way by looking like a care institution. There is a bus service through the estate, but it would not be helpful to several of the residents, and they are assisted to access the community, their friends, and any appointments that they need to keep, through a mixture of taxis and appropriate transport belonging to the provider. There is a large care complex at the other end of the estate, and this has proved to be very beneficial to the residents of this home both in terms of individual activities provided there, and also of the facilities such as the cafe/meeting area that has been the venue for some residents to make new friendships. There are also a variety of shops on the estate and a public house. Furniture and fittings are of good quality, and the construction of the home provides corridors and doorways wide enough to allow wheelchair access to all areas of the home needed by residents. During a tour of the building several bedrooms were visited. These were found to be well equipped, personalised, and of adequate size to accommodate any aids or adaptations that might be necessary for the resident, or for them to engage in any pastime or hobby, or to entertain family or friends. All bedrooms were fitted with variable height wash basins, though none have the benefit of ensuite toilet facilities. Toilets, bath and shower facilities are located close to resident’s bedrooms, and there are also toilet facilities close to the communal areas. The assisted bathroom has had sensory equipment installed, this serves a triple function of meeting hygiene needs, being an enjoyable place in which to be bathed, and a safe area to alleviate tension and encourage relaxation. The home is fitted with hand rails in the corridors, and appropriate aids and adaptations in each of the toilets. The Annual Quality Assurance Assessment (AQAA) document completed by the care manager, confirmed that the servicing of equipment had been undertaken. The premises were clean, hygienic, and free from offensive odour. The home has a good system in relation to infection control, this includes appropriate hand washing facilities, laundry, and health and safety measures. 63 Hoveringham Drive DS0000008319.V345175.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): 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. Staff in the home are trained, skilled, and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: Staff training was discussed with the Care Manager, two staff were interviewed during the afternoon, and staff training records were examined. Staff spoken with confirmed that they had undergone appropriate recruitment/CRB Police checks prior to taking up employment at the home. They also confirmed that the provider was exceedingly pro-active in offering training to its staff together with supervision and support. The AQAA document, and the training and development record, completed by the care manager showed that mandatory and specialist training of staff had been undertaken, and according to the care needs of the residents. 100 of the care staff in the home are current holders of the emergency first aid certificate, and nearly all staff except for 1 staff member, hold the NVQ level 2 award or above. All care staff are responsible for the administration of 63 Hoveringham Drive DS0000008319.V345175.R01.S.doc Version 5.2 Page 20 medication and receive adequate training for that. Mandatory fire safety training is carried out once every two years, as well as 3 monthly fire drills, and training in moving and handling and first aid. Food hygiene, abuse, sexuality, and the origins and management of behaviours are refreshed every three years, and staff had received a three-day course in the management of actual and potential aggression (MAPA). Control of Substances Hazardous to Health (COSHH) training, medication training, infection control, and manual handling training. New employees undertake a full induction course that also covers finances. Staff retention at the home is very high, and staff do stay for many years. Staff spoken with confirmed that the organisation provides a good place to work. All staff spoken with confirmed that they have regular supervision as per the National Minimum Standards (NMS). 63 Hoveringham Drive DS0000008319.V345175.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 and 42 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is based upon openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The care manager holds all the necessary qualifications to fit her for her post, and she has copious experience of running a care home for people with Learning Disabilities. She is a first level nurse, and also holds the Registered Managers Award. She has a clear understanding of her responsibilities and staff spoken with confirmed that she is very supportive, open, and fair in the way she manages the home. 63 Hoveringham Drive DS0000008319.V345175.R01.S.doc Version 5.2 Page 22 During the previous inspection, a selection of questionnaires had been sent out to relatives, these were reviewed and found to contain positive comments. On the day of the inspection there were two staff on duty at all times in addition to the care manager, and an extra member of staff was brought in to take one resident to the armchair aerobics session at Berryhill care complex. The commission for social care inspection (CSCI) received regular quality audits from the provider under the arrangements for reporting monthly visits under Regulation 26. The AQAA document which the care manager completed, confirmed that aids and equipment had been regularly and safely serviced. All staff had undertaken 3 monthly fire drills, and the emergency lighting had been regularly tested, fire equipment maintenance had also taken place, and Fire checks had been carried out every evening when the residents went to bed. These reportedly covered examining all extinguishers and fire blankets to ensure that they were in place, emptying the ashtrays, ensuring that furniture had not been moved in such a way as to create a fire hazard, ensuring that electrical equipment had never been left near soft furnishing or curtains, ensuring that all fire guards were in place, checking the alarm control box for fault indicators, ensuring that all newspapers and magazines had been cleared away safely, and that all fire doors had been closed. The home is fitted with three heat and 13 smoke detectors. Fire evacuation procedures have been reviewed, and fire zones established, with regular practice involving all staff. Two sets of fire doors have been added to the central corridor, ensuring the safety of residents and staff, and compliance with fire regulations. The care manager was asked to provide CSCI with written confirmation that this now complies with current fire regulations. 63 Hoveringham Drive DS0000008319.V345175.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 3 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 3 23 3 ENVIRONMENT Standard No Score 24 4 25 4 26 4 27 4 28 4 29 4 30 4 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 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 4 3 X 3 X X 3 X 63 Hoveringham Drive DS0000008319.V345175.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. Refer to Standard Good Practice Recommendations 63 Hoveringham Drive DS0000008319.V345175.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 63 Hoveringham Drive DS0000008319.V345175.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. 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