Inspection on 21/06/07 for 64-66 Ragstone Road

This inspection was carried out on 21st June 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

64-66 Ragstone Road 20/06/08

64-66 Ragstone Road 24/10/06

64-66 Ragstone Road 31/10/05

64-66 Ragstone Road 26/04/05

64-66 Ragstone Road 12/10/04

64-66 Ragstone Road 13/04/04

Similar services:

21 High Street

Vale House

Chestnut Walk

The Old Vicarage

Cherwood House Care Centre

Ashley House

Ascot Nursing Home

Fountain View

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

CARE HOME ADULTS 18-65 64-66 Ragstone Road Slough Berkshire SL1 2PX Lead Inspector Unannounced Inspection 21st June 2007 14:30 64-66 Ragstone Road DS0000011405.V338379.R02.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 64-66 Ragstone Road DS0000011405.V338379.R02.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. 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 64-66 Ragstone Road Address Slough Berkshire SL1 2PX 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) 01753 524869 F/P 01753 524869 Advance Housing and Support Limited Post Vacant Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th October 2006 Brief Description of the Service: The home is two detached houses linked together by an office/reception area and is situated in a residential area, which is close to local shops at Chalvey and the town centre of Slough. There are eight beds for people, between the ages of eighteen and sixty-five, with mental health needs. The home is run by Advance Housing and Support Limited and is staffed 24 hours a day by a team of support workers. The fees are £1,170 per week. 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection process was generated from poor outcomes for people using the service that were identified during an inspection visit in October 2006. This inspection process was carried out through information prior to the visit that was supplied by the home, the people who use the service and staff working there. Additional information was obtained during the day visit to the home and discussion with and observation of the residents, the management and support staff. The home was supplied with surveys for staff and residents to complete and return to the Commission. Four chose to respond. The home was given very short notice of three hours on the day of the inspection visit to ensure that staff and residents would be available. The acting manager was present at the end of the visit. Two of the seven previous requirements made in October 2006 have not been met. What the service does well: What has improved since the last inspection? What they could do better: They need to ensure that the physical health needs of the individual is equally assessed and that suitable care and support planning is implemented to meet those needs. 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 6 The residents living in the home are not protected as the records kept that evidence the recruitment and employment of staff employed do not support that a robust process has occurred. There are two areas that could be improved by improving the logging and monitoring of concerns or complaints and carrying out risk assessments on individuals to support fire officers should they need to evacuate the building. 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. 64-66 Ragstone Road DS0000011405.V338379.R02.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 64-66 Ragstone Road DS0000011405.V338379.R02.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 adequate. This judgement has been made using available evidence including a visit to this service. The assessment process does not ensure that enough information is obtained about the individual’s physical health or previous mental health. EVIDENCE: The care plan records for two people living in the home since February 2007 were reviewed. The home uses an assessment process that includes information provided by the referring social services assessment, mental health professionals and discussion with the individual. The quality of the assessment documents have been improved and developed since the last inspection process. The home’s assessment documents provide brief descriptions of any medical disorders, mental health needs and their current medication. They also discuss the planned personal development goals that would be intended to achieve and how this can be managed. On review of the sample of assessment documents seen it was identified that there were gaps in knowledge about the physical health for one person and that some of the previous mental health history of another had not been included. 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 9 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 support plans give good information to staff for them to be able to meet the person’s personal and social support, but lacks sufficient information about their physical health care needs. EVIDENCE: The care planning and risk assessment processes were reviewed. The two records seen showed that the home implemented a planned programme of personal support, centred around either a recovery of lost skills and the development of new life skills for the individuals to be able to care for themselves. Each person is consulted throughout the process and their consent to the risk assessments and support to be provided is recorded. 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 10 Very little is noted about the personal care support required for the one new resident who has very specific health care needs. Recorded in the support plan is that personal care and assistance is provided by the district nurse and a domiciliary care service, but what this entails is not known. The home has implemented risk assessments that are based on significant behavioural and mental health needs of the person requiring support and in the regard to the risks to others. The records for the support plans and risk assessments are reviewed regularly and are amended when changes are required following the reviews with staff in the home, psychiatrists and any other clinicians involved. 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 11 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. The people living in the home are supported to develop their independence and continue with relationships with their families and friends. The home ensures that they are involved with the choices and preparation of a varied and nutritional diet. They also ensure that any cultural or ethnicity needs are supported. EVIDENCE: The staff informed the inspector that none of the current people living in the home are employed but some are continuing with their education at local colleges. 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 12 Staff ensure that the individual’s support plan includes activities that encourage personal development and independence parallel with guidance from the mental health professionals involved. The majority of the people are semi–independent and require some support from staff periodically for activities outside the home such as health care appointments, visits and outings. Personal friendships and continued contact with family is supported as much as possible. One resident has recently been on holiday with their family. For others, friends visit the home regularly as was seen during the visit to the service. Residents are able to meet privately with the visitors in their own rooms or use the communal spaces in the home. If there is an identified wish by residents to seek support from local churches or faith organisations, they are supported to do so. One resident wrote in the survey, “I am grateful to the staff for encouraging me to develop my skill and helping me to visit my local church.” The staff support service users to have daily routines to promote their independence and ensure that they learn to take some responsibility for housekeeping and the running of the home. The daily routines for the individual are developed in their support plans but they also have tasks they are responsible for such as the midday meals, shopping and for cleaning the communal areas of the home. Each person has a key to their room and is able to go out of the home as they wish but are requested to inform staff when they do so. Contracts are agreed to conduct and responsibilities for living in the home that include smoking in bedrooms and communal areas. The staff and service users are responsible for the development of the meals and menu planning for the home. Staff stated that they usually discussed the menu plan for the following week before the weekend and the main shopping trip. Residents are requested to select the planned meals and staff ensure that any specialist dietary needs are taken in to account, such as Halal meat. The meals and meal preparation are usual topics for the regular home meetings where staff and the residents discuss plans and voice their opinions of how the home is run. Individuals are responsible for making their own breakfasts and for their evening meals from a selection of food bought for this purpose. They also have the opportunity to go out of the home to buy food of their choice. Staff do monitor what each person eats whilst they are in the home and encourage a balanced meal plan. One resident has been assisted by staff to be referred to for professional nutritional advice following changes to their physical health needs and, as yet, do not know how this will affect the current meals and menu planning. 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 13 The dining area is arranged so that there are sufficient areas for all the residents to take their meals together and to be included in the meal preparation. 64-66 Ragstone Road DS0000011405.V338379.R02.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 adequate. This judgement has been made using available evidence including a visit to this service. The insufficient information that is obtained about the individual’s health and medical needs could compromise ensuring that they get the support that they require. EVIDENCE: The two support plans were reviewed to assess if assistance with personal care is required and if there are any healthcare needs that should be met. The home offers support, behavioural plans and some rehabilitation to people whose primary needs are mental health long term conditions. Some of the residents have been living there for several years and have gradually built on their personal skills to manage their own lives. Others have been admitted following a mental health event and require interim support to regain their confidence to live fully in the community. 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 15 The records reviewed showed that the assessment process and subsequent support plans do not necessarily give good information about the individual’s physical health needs or previous mental health that could effect the care and support they require. The records for the one service user who obtains personal care support from the local social services home care service, are unclear of what they provide. The medication needs for the individual are recorded in their assessment records and are reviewed by the clinicians at the their monthly consultations. Staff confirmed that none of the residents are self-medicating on a regular basis, but are able to do so only with written consent of the psychiatrists who care for them. This is when they are away from the home for a period of time such as appointments, shopping and days out. Staff have carried out risk assessments for this and can use these to assess at the time if the individual is well enough to do this. Staff are provided with medication training in the induction programme and are required to complete written and practical assessment before they are allowed to carry out any administration. When discussing with the staff the medication practices in the home, they confirmed that the residents are responsible to attend a central point in the home where usually two staff work together to ensure that compliance and safe administration occurs. The records for the administration of the medication show that staff are recording any activity appropriately. All incoming and outgoing medications are recorded and are stored in safe facilities in the home. They could keep photographs of the individual with the medication administration records so as to provide added support to ensure that medication is being given to right person. The home has provided information that the policies and procedures for the control, storage and administration of medications in the home have not changed since the last inspection process where they were found to appropriate for the service. The residents in the home range from their early thirties to middle sixties and at present staff do not routinely seek the individual’s choices and wishes about how they would like to be cared for if at the end of their life and following their death. However, they may need to review and plan how they seek this information as they have some service users who have been living in the home for several years, who may still require their support for a long time, and may not have family or advocates to voice their choices on their behalf. 64-66 Ragstone Road DS0000011405.V338379.R02.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. The staff listen to concerns and complaints made and implement actions appropriately. The people living and working in the home are protected by the training and information given to staff about safeguarding adults. EVIDENCE: The home has a complaints policy and procedure that is provided in the Statement of Purpose and Service User Guide given to residents when they are admitted to the home. It is also on display prominently in the lobby area of the building for visitors to see. Staff routinely discuss concerns and anxieties in the regular communal meetings where the people living there are able to air their comments about what is happening in the home. They record all discussions and decision making from these meetings and note any comments that are made in between these meetings in the home’s diary/message book. What was identified on review of the records available in the home is that staff may not be recording information in the right place or using the formal complaints process at the time the concern was expressed. The acting manager was unable to locate the complaints records held in the home during the inspection visit. They also do not have a system of analyzing trends of the concerns expressed by the people living and working in the home. 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 17 What was stated by the majority of the people spoken to during the visit and by those who contributed to the surveys carried out, was that the staff usually listen and act upon concerns swiftly. The Commission was not in receipt of any concerns, complaints or information about the service since the review carried out in October 2006. Staff are given training and information about safeguarding adults in the induction training and in the improved training programme that has been implemented since the last inspection process. Copies of key documents, policies and procedures are in place in the home to provide staff with information and guidance should concerns arise. Evidence was seen during the day of staff monitoring relationships between residents and implementing interventions successfully when disagreements occurred. 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises are suitable for the needs of the people living there and to achieve the service that they provide. It is kept clean and hygienic and provides a homely environment. EVIDENCE: The home is two detached properties that are linked together by a central extension and is located in a residential area near central Chalvey in Slough. The home has bedrooms on the ground floor and first floor with shared bathrooms on both floors. The upper floors are not connected together and there are two separate stairways to each area. The communal areas include a large and small lounge with a kitchen/diner and garden to the rear of the property. The laundry is of a moderate size, accessed through both the dining area and the small lounge and away from food preparation areas. Each resident has their own bedroom that they can furnish, decorate and personalise as they wish. Staff are provided with a small area for ‘sleep in’ duty that is situated at the rear of the office area. 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 19 The home is generally in a good state of repair and decoration, with some deficits with the small lounge area showing signs of its prolonged use as a ‘smoking room’ by the residents and a minor repair needing to be carried out on a cupboard door in the laundry. The garden appears to be underused and could be made a little more user friendly by better provision of seating and safer pathways. One service user who accompanied the inspector around was not confident to walk around the garden as it has irregular steps between the back door to the brick built games room at the rear. Most of the communal areas seen are clean, tidy and hygienic with staff and residents sharing tasks for ensuring that the housekeeping is carried out. Each resident is wholly responsible for keeping their own bedrooms clean and tidy and for their own laundry, but they are prompted by staff where necessary as part of their support programme. 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The evidence kept in the home for the recruitment of staff does not support that a thorough safe process is carried out. The training provided to staff has improved and ensures that the majority have a good understanding of the possible mental health needs of the people living in the home. EVIDENCE: The duty rota, records for employment, training and supervision for staff were reviewed to assess that there were sufficient skilled and experienced staff employed in the home to meet the needs of the service and the residents. A discussion with staff and the acting manager and a review of the current rota indicated that staffing levels had been increased by the employment of bank staff and that they ensure that a minimum of three staff are present in the home at all times during the day and two at night. The information provided by the home indicates that only one member of the eleven permanent staff has acquired an NVQ 2 or above and that five are now registered for training to do this. 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 21 None of the bank staff have any formal qualification in care. However, some are experienced care workers or are undertaking training in mental health nursing. Through discussion with staff present in the home and a review of the training records, it was clear that many of the staff had undertaken specific training for them to have an understanding of some of the more well known mental health disorders, their treatment and how to care for people who may be living in the home. Additional to this some staff have been given training for challenging behaviour and communication. The training programme for the key topics of health and safety has improved and the majority of staff have completed most of the required training. Copies of all training and induction for staff are kept in the home. The recruitment and employment records of three staff who had started working in the home since August 2006 were reviewed. The home only keeps copies of the key documents that are held centrally by the provider organisation who is responsible for the recruitment process being completed. Applicants are required to complete an application form and provide evidence of their identity, training and information about their health history. The application forms seen did not give the full work history or give explanations of gaps between schooling and employment periods. Two references are requested but in the case of one applicant there is no evidence that the individual had worked for the company that the reference was from. Proof of identity was missing from one applicant’s file and written confirmation of the Criminal Records Bureau check carried out with the reference number included did not state whether it was an enhanced check necessary for working with vulnerable adults. Two files showed that photographs of the staff member had been taken and identity cards issued, but not for the bank care staff member. Two staff had a record of health screening clearance and one did not. Evidence of interview and decision making to employ the applicant was not seen in the records kept in the home. 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42, 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run effectively and safely and the residents’ opinions of the service are sought regularly. EVIDENCE: Two temporary members of senior staff, since October 2006, have been responsible for the management of the service. The current acting manager informed the inspector that the recruitment process to employ a permanent member of staff to the position has commenced. The certificate of registration on display in the home does not give accurate information about the registered manager post. 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 23 There are several methods that the staff use for seeking the opinions of the people who live in the home about the service that is provided. This is done through regular resident/staff meetings, reviews of care, periodical surveys and visits by the provider organisation in accordance with Regulation 26. Other healthcare professionals are able to feedback their opinions through the reviews of care they carry out. What was evident during the inspection visit was that the staff took time to listen to residents and responded in a supportive manner. One service user wrote in the survey from the Commission that the home was “Better than before”. Another stated in regard to what they thought the home did well, “They provide good food, keep the house tidy and manage the home well”. The home has policies and procedures for safe working practices and to ensure that the home is properly maintained and safe to live in. As previously stated, the training programme for staff about the key topics for safe working practices such as food hygiene, first aid and fire safety have been provided to most of the staff. The home provided information that they have carried out the necessary maintenance checks for the heating, gas, water and portable electrical equipment. They also provided information that they have suitable systems in place for the disposal of soiled contaminated waste and have procedures and information for the safe storage and use of cleaning materials(COSHH). Staff routinely check the temperatures of any fridge and freezers that are used for the storage of food in the home and ensure that safe food handling by staff and residents is carried out. There are regular fire drills carried out with the full participation of all the residents in the home and checks are made for the fire safety equipment placed around the home. There are some risk assessments carried out for the general safety of the residents, staff and the environment but not individual ones for the residents should the fire brigade need to enter the building without the support of a staff member. 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 2 2 3 2 2 X 2 X X 3 3 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 25 Yes 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 YA2 Regulation 14(c) (d) Requirement To ensure that assessments evidence that the home is able to meet the needs of the service users. Previous timescale not met 01/01/07 Timescale for action 31/08/07 2. YA19 12.1(a) To ensure that staff have enough 31/08/07 information to enable them to promote the health of service users. Previous timescale not met 01/12/06 That the home ensures that it can provide evidence that a robust recruitment process has been carried out. 31/08/07 3 YA34 19, Schedule 2 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA22 Good Practice Recommendations That they implement a system of monitoring and analyzing concerns and complaints made to the home. That they could carry out risk assessments on individuals to support fire officers should they need to evacuate the building. 2. YA42 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 64-66 Ragstone Road DS0000011405.V338379.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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