Inspection on 26/02/07 for Rose Orchard

This inspection was carried out on 26th February 2007.

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

The inspector 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

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10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Baxter Avenue, 7 7 Baxter Avenue Kidderminster Worcestershire DY10 2EU Lead Inspector Dianne Thompson Key Unannounced Inspection 26th February 2007 10:30 Baxter Avenue, 7 DS0000066933.V331344.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 Baxter Avenue, 7 DS0000066933.V331344.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. Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Baxter Avenue, 7 Address 7 Baxter Avenue Kidderminster Worcestershire DY10 2EU 01562 750375 01562 750375 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) Praxis Care Group Mrs Anita Jane Cant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home provides accommodation for adults with learning disabilities and associated physical disabilities 9th January 2006 Date of last inspection Brief Description of the Service: Baxter Avenue is a spacious purpose built bungalow close to the centre of Kidderminster. It is a home for people with both learning and physical disabilities. The home aims to provide nursing care and appropriate support to meet the needs of service users. Specifically this will include promoting independence and opportunities to make real choices in every day life. The registered manager is Anita Cant. Praxis Care Group is the registered provider, and the Director of Care Irene Sloan is the Responsible Individual. Praxis Care Group became the registered provider on 1st April 2006. The current fee for the service is £1244.31 per week. Charges which are additional to the fee include: • • • • • • • Personal toiletries, clothing and electrical items (TV and music centre). Activities not covered by the allowance made by the provider or in the funding authority contract Holidays Major extra outings Hairdressing Reflexology Beauty therapy Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that included an unannounced visit to Baxter Avenue. This was the home’s first inspection since Praxis Care Group registered as the care provider. The main purpose of this inspection was to see what the service at Baxter Avenue was like for the people who lived there. Service user records were examined, and a tour of the building was also carried out. Accumulated information including notifications to the Commission for Social Care Inspection was used to inform this report. Time was spent with two service users, staff on duty and the registered manager. Surveys were sent out to relatives and people who work in the medical services prior to the inspection visit. What the service does well: Baxter Avenue is located in a residential area of Kidderminster. The home is a purpose built bungalow where five people who have learning and physical disabilities live. The home is spacious with bathrooms, toilets and special equipment to support service users. Baxter Avenue is a safe and comfortable home that is kept clean and tidy. The home has recently been redecorated. Information is available about the services offered at the home to help people choose whether or not to live at Baxter Avenue and if the home can meet their needs. Service users are helped and supported to lead active and interesting lives at Baxter Avenue. They are also supported to stay in touch with their families and to develop friendships. The home offers a well-balanced diet. Personal and healthcare needs are written in care plans and give information to staff to make sure that care is provided in the way service users like. The home has a medication policy and procedure to make sure that all medication is given and stored safely for the protection of service users and staff. Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 6 The home’s complaints procedure has easy to understand information about how to complain. Staff support service users to have their say and to share any concerns they may have. Staff are trained to help them support service users. The staff team understand their responsibilities and are committed to their role. They are well supported and work together to provide service users with consistent and good quality care. The home is well managed in an open and positive way. Praxis monitors the home in various ways to make sure the service continues to develop as service users want and that the home remains a safe place to live and work in. 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. Baxter Avenue, 7 DS0000066933.V331344.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 Baxter Avenue, 7 DS0000066933.V331344.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 excellent This judgement has been made using available evidence including a visit to this service. Prospective service users are given information about the services offered at the home to help them make an informed choice about whether they would like to live at Baxter Avenue and whether the home will meet their needs. EVIDENCE: The home’s statement of purpose and service user guide has been amended to provide up to date information about the home to help prospective service users decide if they wish to live at Baxter Avenue. The service user guide was updated in February 07 to reflect changes within the home. The home has an admissions policy and procedure in place and evidence was seen which shows that they are being followed for a planned admission to the home. The assessment process is very detailed and the service users care records show that the home receives full information about prospective service users, their background, their needs, their likes and dislikes when they are referred for a placement. Information is gathered from a range of sources such as other relevant professionals, visits to previous homes or schools, and discussions with family members. Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 9 Introductory visits and stays are arranged at the home prior to admission. During the introduction to the home prospective service users are given a copy of the Statement of Purpose and Service User Guide. The registered manager said that copies of the Statement of Purpose and Service User Guide are accessible to all, including visitors to the home. All service users receive copies of relevant information prior to moving into the home, which is offered in preferred formats, such as symbols, pictures, audio and large print. Surveys were sent to all service users and their relatives prior to the inspection visit. Eight responses all confirmed that they had received information about the home and that they had visited prior to moving into the home. Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Care plans provide staff with detailed information about service users assessed needs. They include risk assessments to show how risks are to be reduced and how to promote independence. Service users are supported to make choices and decisions in their daily lives and routines. EVIDENCE: Service user care plans are detailed and informative. The plans show monitoring of identified goals, and how these are to be facilitated and achieved. Staff have information to make sure that all care is provided in a preferred and consistent way that encourages independence. Risk assessments are completed for individual service users and include assessments for the use of bedsides. Manual handling guidelines give clear instructions and pictures for all staff to follow to maintain a consistent approach. Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 11 Files for two service users who have different needs were examined. Case tracking provides a view of how the home responds to the diversity of needs and how this is being managed and supported. This is particularly evident where health needs and disability requires greater input and support from all staff within the home. Relevant information and monitoring is provided in service user files to make sure all staff have the necessary information to provide quality care. Each service user is allocated a key worker and a co-key worker to oversee their care. Each key worker builds a closer relationship so they gain more understanding and knowledge of individual needs, goals and wishes. Plans are reviewed regularly or as any changes in need occur. Staff are fully aware of the plans and clearly use them to guide their practice. A person centred care plan (PCP) approach is being developed within the home and service users will be appropriately involved in planning and reviewing their own care. Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users receive help and encouragement to lead active and interesting lives and are supported to access facilities within the community. They are also supported to maintain links with their families and to develop friendships. The home offers a well-balanced menu and promotes healthy eating for the welfare of all service users. EVIDENCE: Two service users were out for the day at the time of the inspection visit. Time was spent with the two service users at home. The home provides a range of activities for service users, both in-house and within the local community. Activities are organised according to individual likes and dislikes and all service users are encouraged to participate. Activities are recorded in files providing a clear record of individuals’ lifestyles. Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 13 A music session took place during the inspection. A harpist who visits the home on a regular basis provided the music. The music of the harp and the singing was obviously enjoyed by all. Service users are supported to choose activities using their weekly planner. The weekly planners were seen. Activities within the home include watching TV and video’s, massage and aromatherapy, music therapy, sensory sessions, foot spa, make up sessions, and relaxation exercises. External activities include Snozelen sessions at the Pear Tree Activity Centre in Merry Hill, visits to the cinema, attending Hammers football matches, visits to the local pubs, shopping, and bowling. Records show that service users are supported to keep regular contact with their friends and family. All surveys indicated that they were satisfied with the overall care. The home provides well-balanced, varied meals and special diets for individuals where required. Alternative options are available for service users and supper is provided. Food charts are kept in the kitchen. Baxter Avenue, 7 DS0000066933.V331344.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 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Personal and healthcare needs are clearly identified in care plans. The plans provide information and promote consistency of care and support for all service users in a way that takes into account their preferences. The home has a clear medication policy and procedure, which is followed to make sure that all medication is administered and stored safely for the protection of service users and staff. EVIDENCE: Service users’ care records and plans provide detailed information about their physical and mental health and the support needed from staff to maintain their good hygiene and health. The care plans sampled contain information about service users preferred personal care routines. Individual mobility and handling guidelines are compiled for each service user. These guidelines provide details of positioning, details of slings to be used and the positioning of straps on the slings. This ensures that all staff are informed and work to preferred and agreed procedures. Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 15 Care plans are regularly reviewed and updated as required or as identified needs change. Staff are able to communicate with service users verbally and, in certain cases, with the additional use of gestures, sign language, and using objects of reference. Time was spent with service users who were at home during the inspection visit. Although communication was difficult, everyone seemed to be comfortable and well cared for in the home. Records of all physical checks are completed where service users have particular health issues such as weight and fluid intake. In this way the home is able to closely monitor and respond to changes or obtain appropriate medical input whenever necessary. Record keeping and information is very detailed and thorough. Service users and the home are well supported by medical services, which includes GP’s, , epilepsy consultant, psychiatrist, dentist, community learning disability team, occupational health therapist, and dietician. Arrangements are in place for preventative health services, such as dental checks and annual health screening. Staff on duty and the registered manager confirmed that all personal care is given in private to promote dignity for all service users. The manager is very aware of the specialist services that could be needed to support service users and how to access them. The home has a medication policy and procedure in place. Medicines are suitably and safely stored and a new cabinet has been purchased for the storage of controlled drugs. Information is available to advise staff about prescribed medication together with any possible side effects. A medication information fact sheet is provided both in individual files and in the medication file for each service user and gives details of all current prescribed medication. Consent to treatment forms have been completed. Survey forms returned by medical professionals indicated that staff demonstrate a clear understanding of service users care needs, and communicate well with other agencies. The surveys also confirmed that instructions relating to changes in health care for service users are incorporated into care plans. The registered manager has recently completed a palliative care diploma and will now work with service users, their families and staff to complete their end of life pathways. Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are protected by easy to understand information about how to complain, with appropriate information for staff provided. Staff support service users to express their views and any concerns they may have. EVIDENCE: Baxter Avenue has a suitable complaints policy and procedure in place. The complaints procedure is available in alternative formats where appropriate. There have been two complaints to the home since the previous inspection. These have been responded to within the required 28-day timescale. One complaint was fully upheld and the second complaint partially upheld. The registered manager confirmed that appropriate action had been taken in response to these complaints. No complaints have been made to the CSCI since the previous inspection. All of the surveys indicated an awareness of the complaints procedure, and two confirmed that they had not made any complaints to the home. One survey stated that an informal complaint had been made and the home had responded to this. The medical professional surveys indicated that no complaints had been received about the home. Relatives’ comments on behalf of service users indicated that ‘staff support service users to make complaints’, and that the service users ‘have a good relationship with the staff and would let them know if there was anything Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 17 wrong’. Applications have been made for advocacy support where service users do not have family support. There are suitable policies and procedures in place to support staff to keep service users safe. During the inspection visit staff were observed engaging with service users in a supportive and respectful way. Praxis Care Group considers staff training on abuse and protection to be mandatory. Staff training has been completed and meets a recommendation from the previous inspection. Copies of ‘no secrets’, the Healthcare Commission report on recent investigations and enquiries, and the Adults at Risk policy are available to all staff for reading. There is also a signatory list for all staff to sign to confirm they have read these documents. The registered manager said that these documents are also agenda items for staff meetings. The home has relevant financial policies and procedures in place to make sure service users money is kept safe. Service users are supported to keep their money in a safe in their bedrooms. Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Baxter Avenue provides accommodation for service users that meets their needs and offers a safe, spacious and comfortable home. The home is kept clean which ensures that good hygiene and infection control is maintained for the benefit of service users. EVIDENCE: A tour of the home was completed. Baxter Avenue is a spacious purpose built bungalow, with five bedrooms, two bathrooms, separate toilet, laundry and fully fitted kitchen. There is an open plan dining room and lounge with sliding doors to separate the rooms if required. The home has been redecorated throughout. The redecoration has been very nicely done. The appearance is pleasing and there is a good atmosphere in the home. Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 19 The enclosed gardens are attractive and well laid out, with raised beds and a shed, which is accessible and well used. A new bird table and a swing have been added to the garden since the last inspection. Specialist equipment is available as required. This includes specialist baths, overhead and manual hoists. Ceiling fanlights have been fitted to all the bedrooms. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. Communal bathrooms have paper towels and liquid soap available and there are suitable arrangements in place for the disposal of clinical waste. All cleaning materials are stored in locked cupboards in the laundry room. Staff were observed wearing appropriate protective wear for the task being completed. A maintenance networking relationship has established greater understanding of the home’s needs with the maintenance contractor and has resulted in improved timescales and responses to required work. Tiles need to be replaced in shower room around the toilet, where they have cracked and loosened. This was discussed with the registered manager. Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staffing levels are being maintained and staff receive relevant training to help them meet service users’ needs. The staff team understand their responsibilities and are committed to their role. They are well supported and work together to provide service users with consistent and good quality care. The home’s recruitment policy and practices make sure that suitable staff are employed and that all necessary checks are made to ensure the safety of all service users. EVIDENCE: Staffing levels are being maintained although some staff vacancies have remained unfilled since the last inspection. The home uses agency staff when cover is needed, but takes care to use the same agency and where possible, the same staff to ensure familiarity and consistency of care for the service users. Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 21 The manager said that the change to Praxis Care Group (the new provider) has been relatively smooth. The service users and staff have coped with the change of provider very well and have seen the transition period as a very positive experience. Praxis Care Group provides regular staff training. Staff complete mandatory training such as health and safety, fire safety, first aid, food hygiene, moving and handling, infection control and abuse. Other training courses include communication, palliative care, fire training, health and safety, infection control, vulnerable adults, bereavement, and food hygiene updates. Further training is planned for the coming year to include first aid, epilepsy and vulnerable adults. Two members of staff are currently completing NVQ training. All newly employed staff complete an Induction Course. The Induction process also includes new staff being supported by senior staff to familiarise themselves with the home, service users and safety matters. A sample of staff records was examined. The manager confirmed that all prospective staff complete an appropriate application form and that required references are obtained including one from their most recent employer. Appropriate criminal records and other checks are undertaken before their appointment is confirmed. All staff are required to work a probationary period at the home. Evidence was seen from the staff supervision planning chart that all staff receive regular structured supervision from the management team. Staff meetings are held regularly and minutes are available. Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The home is well managed. Praxis monitors the home in various ways to ensure that the service continues to develop as service users want and that the home remains a safe place to live and work in. EVIDENCE: The registered manager and one of the assistant managers was available at the time of the inspection. The registered manager, Anita Cant is a registered nurse and has recently completed a Diploma in Professional Practice in Palliative Care Course. Management responsibilities in the home are shared with four assistant home managers. They are all involved in organising day-to-day activities, health and safety promotion, staff supervision and induction. Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 23 In respect of management support from the provider, Praxis has Training and Human Resource Officers who are available to advise and support the home. Service manager meetings are held regularly and the manager confirmed that she and the home are being supported. The provider’s monthly visits are one of the ways that Praxis monitors the service and how the home is being run. These visits include interviews with staff and service users and also include an audit of relevant aspects of the service, including records, environment, complaints received, finance and safety. Any actions that may be needed to address shortfalls are specified. The resulting reports are also part of the home’s quality assurance and monitoring system and are intended to form an annual development plan for the service. This report will include service users, stakeholders and interested parties views on the service provision. Strategic Planning sessions and Quality Assurance training for the management team is scheduled for the coming week in Ireland. Praxis is also making an application for consideration for the Investors in People award. Records show that monthly checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. Staff are undertaking all mandatory health and safety training topics. Generic risk assessments are in place. A full fire inspection was completed by a fire agency on 17/11/06, and a detailed risk assessment compiled. An automatic door closure was recommended for the office and this has been ordered. The home was advised to revise the evacuation plan to include horizontal evacuation. Aids to assist with horizontal evacuation, such as ski sheets, were discussed with the registered manager as an option for consideration should such an evacuation become necessary. Fire drills and required checks are being completed. The last fire drill was recorded as 01/02/07. This meets the requirement of the previous inspection. The Environmental Health Officer visited in January 2007. No requirements were made. The registered manager completes a health and safety audit every three months. Copies of the previous audit were seen. Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 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 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 3 34 4 35 4 36 3 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 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 4 X X 3 X Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA27 Good Practice Recommendations The cracked and loose tiles to the bathroom wall should be replaced. Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 26 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 Baxter Avenue, 7 DS0000066933.V331344.R01.S.doc Version 5.2 Page 27 - 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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