Inspection on 05/12/06 for 7 to 9 Third Avenue

This inspection was carried out on 5th December 2006.

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

The inspector found 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

7 to 9 Third Avenue 10/01/06

7 to 9 Third Avenue 02/03/05

7 to 9 Third Avenue 02/09/04

7 to 9 Third Avenue 10/03/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Third Avenue (7/9) 7/9 Third Avenue Wickford Essex SS11 8RF Lead Inspector Mrs Bernadette Little Unannounced Inspection 5th December 2006 10:25 Third Avenue (7/9) DS0000018078.V327354.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 Third Avenue (7/9) DS0000018078.V327354.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. Third Avenue (7/9) DS0000018078.V327354.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Third Avenue (7/9) Address 7/9 Third Avenue Wickford Essex SS11 8RF 01268 571865 01268 571865 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) Estuary Housing Association Limited Mrs Penny Luxton Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Third Avenue (7/9) DS0000018078.V327354.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 Brief Description of the Service: 7 and 9 Third Avenue are two purpose-built semi-detached bungalows with an interconnecting door, located in a quiet residential area of Shotgate, and within walking distance of the local shops. Care and accommodation is provided for six adults with profound learning and physical disabilities. The home provides accommodation in single bedrooms and there are specially adapted bathrooms and toilets. Each bungalow has independent facilities, number 7 has a lounge/ diner and a separate kitchen, while number 9 has an open kitchen/dining and lounge area. The front of the house has parking space and an attractive garden and is in keeping with other houses in the street. There is a secure rear garden, which has been designed with the residents in mind and has scented plants and water features. The home has a minibus to assist residents to attend leisure and social facilities in the community. The home also has a mobile sensory unit, which can either be used by residents in the communal areas or in the privacy of their own room. The pre-inspection questionnaire identifies the weekly fees as being £1,805.26. Additional charges/costs identified as incurred by residents relate to hairdressing, personal toiletries, family gifts for special occasions, all of which vary, with a £15 charge per month for any resident who attends additional aromatherapy. The pre-inspection questionnaire also identifies that residents may have additional costs for staffing for holidays and that this will vary according to the circumstances. The Service Users Guide additionally advises that residents will be required to purchase items for personal use such as televisions for their bedroom, as well as their bedroom furniture and any specialist equipment they need. Third Avenue (7/9) DS0000018078.V327354.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was undertaken as part of the key inspection of 7/9 Third Avenue and approximately seven hours were spent at the home. Time was spent with all six of the residents who were living at the home at the time of the inspection. Most of the residents were unable to express views verbally due to their profound learning and communication disabilities, but observations of practice and responses to non-verbal communications are included in this report. Five staff and the registered manager were spoken with. A tour of the premises was undertaken and records, policies and procedures were sampled. Records for one resident were case tracked and were sampled for another resident. Discussion of the inspection findings took place with the manager and staff during the inspection and the help given by residents and staff was appreciated. Requests for information were sent to a GP and a social worker. No responses were received. A particularly well completed pre-inspection questionnaire had been received from the registered manager prior to the unannounced site visit, supported by clear documentation such as training records, menus and financial information. This, and the assistance of all those at 7/9 Third Avenue is appreciated. What the service does well: What has improved since the last inspection? The home have been able to employ two new permanent staff and this will help to continue to provide familiar faces to residents. Third Avenue (7/9) DS0000018078.V327354.R01.S.doc Version 5.2 Page 6 Staff have had a training on subjects that particularly about residents need like communication and helping service uses to express themselves. The statement of purpose and service user guide had been sent to the commission. Medication records and administration was better. There were records to show that the heating and water temperatures were satisfactory for residents and that staff had taken part in regular fire drills. The toilet and bats front door is that opened out words into the hallways had warnings on. 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. Third Avenue (7/9) DS0000018078.V327354.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 Third Avenue (7/9) DS0000018078.V327354.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, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available about the home that would help prospective users of the service to make a decision about living there. Each resident had information about what they can expect from the home in their statement of terms and conditions. EVIDENCE: The statement of purpose and service user guide had been reviewed and copies had been sent to the Commission. The service user guide will now need to be updated to reflect the changes in Regulation that came into effect in September 2006. A copy of the statement of purpose and service user guide was contained on the resident file. There have been no admissions to the home since the last inspection. The registered manager’s confirmation of the homes admission process, and Estuary’s supporting documentation clearly identifies that prospective residents will have a detailed pre-admission assessment, including input by relevant professionals, as well as trial visits to ensure the appropriateness of the placement. Each resident file sampled contained a pictorial Statement of Terms and Conditions that was written in plain language and contained pictures. This was supported by a Licence to Occupy agreement. Third Avenue (7/9) DS0000018078.V327354.R01.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 written information in the care plan clearly explained to staff how to look after each resident in the way that was judged best for them. Staff were able to show that they knew what was in the care plan and were seen to put this in practice in caring for residents, so that residents knew what they could expect and would have familiar structure in their care. Staff tried to interpret residents’ communications to involve them and help them make choices. EVIDENCE: Three care plans were looked at for various issues and one tracked in detail. This covered 17 different aspects of the resident’s daily life and needs and included issues such as finance, aspects of personal care, aspects of nutrition and independence, daily activities and community presence, promoting independence and choice, management of challenging behaviours and interaction. There was no care plan relating to medication. In addition to having clearly identified needs/clear instructions for staff on how to meet these on a daily basis in the care plans, it was noted positively that Third Avenue (7/9) DS0000018078.V327354.R01.S.doc Version 5.2 Page 10 staff spoken with were actually aware of residents individual needs, personalities and abilities, and of how they supported residents to put these in place each day. Care plans were supported by risk appreciation or assessment, for example in relation to aspiration, travelling safely, hoisting into the swimming pool and a 13 step risk management plan for challenging behaviours, with monitoring. A daily record was maintained of the implementation of each area of the care plan as it occurs. Residents at Third Avenue have no, or very limited, verbal communication. Staff advised they do try to interpret indications of residents’ choices and preferences. Staff were able to show that they were able to interpret residents’ communications, for example a resident saying the word ‘feet’ means from experience that they wanted you to go away. Staff confirmed that all new or agency staff were required to read the care plan for each resident at the outset. Third Avenue (7/9) DS0000018078.V327354.R01.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 manager and staff had identified varied activities that were based on their knowledge of residents’ needs, age, abilities and preferences. Resident opportunity could be improved with additional resources. Residents were provided with a nutritious diet. EVIDENCE: The whiteboard in the office clearly denotes both morning and afternoon and evening activities and any other planned events for each individual resident. This clearly identified that social and leisure activities occur at weekends and in the evenings, as well as on weekdays. A long serving staff member expressed the view that getting residents out and about is the success of the home. Three residents have opportunity to attend the Wickford Exchange at different times. Two residents belong to the Seals swimming club that meets on Sundays. Three residents regularly go home to visit family. Records also demonstrated for example that residents attend Sunday worship, music club local social club. Third Avenue (7/9) DS0000018078.V327354.R01.S.doc Version 5.2 Page 12 One resident had had reduced opportunities as Bentons farm closed. The registered manager confirmed that she had been able to access an additional 15 hours of funding to support this resident. Two other residents also lost similar opportunities. In the interim, staff are endeavouring to take the residents to a local over 50s club. Senior staff advised that the registered manager had applied for additional staffing hours funding but this has been shelved as the service manager had left. Estuarys quality review report identifies this as an area for development. Staff were aware of resident individuality and their varying abilities to cope with different social settings and community involvement, for example in relation to noise or changes in environment. In some cases residents are advised as being taking out for an activity, but feeling unable to leave the minibus and needing to return home, which staff respected. Staff were also aware of activities that residents enjoy at home and some of these were seen to be occurring during the inspection. The home has mobile sensory equipment, which can be used in either house and depending on the residents’ needs and preferences. Staff advised that for a resident who is totally non-verbal, they try asking, offering choices and interpreting the non-verbal responses but where aware that the person may not actually be actively choosing. Other residents were clearly able to indicate choices when offered for example the containers for tea and coffee. One resident is able to take some steps to assist in helping to make a cup of tea. Ample food stocks were available. A detailed record is kept of the food and drinks consumed by residents each day. A varied rotating menu was provided with the pre inspection questionnaire. The registered manager confirmed that three residents are on puréed diets. She confirmed that for two residents, all foods are individually puréed and served, but that another resident, because of their specific need, the foods are puréed together to produce a soup like consistency. The home are working with the nutritionist and osteoporosis nurse for two residents as well as the nutritional team at Basildon Hospital to ensure the best possible nutritional outcomes for residents. Third Avenue (7/9) DS0000018078.V327354.R01.S.doc Version 5.2 Page 13 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 good. This judgement has been made using available evidence including a visit to this service. Staff training and knowledge and the provision of appropriate equipment ensured that residents received personal support to meet their needs and to respect the dignity. Residents were provided with support to meet their health-care needs. Medication systems and practice protected residents. EVIDENCE: Discussions with staff and observation of practice indicated that staff were aware of residents support needs and how these were to be carried out as identified in care plans and risk assessments. Staff respected resident’s privacy and dignity, and comments were offered such as “residents have a right to privacy” or “use good manners”. They were also able to indicate that they ensured that residents views were ascertained as much as possible about transfers and personal care, while ensuring that all safety equipment was in place and that they were close by for example because of issues such as seizures. Records indicated that residents are supported to access all necessary health care professionals and services to meet their individual needs, and issues were cross-reference within the care plans. Third Avenue (7/9) DS0000018078.V327354.R01.S.doc Version 5.2 Page 14 Records indicated medication received and returned including appropriate signatures. Medication Administration Recording sheets were well maintained and contained a photographs of each resident. The records for the care file tracked indicated a protocol to manage ‘as required’ medication and appropriate medication review. Staff advised of a preference to use positive responses to manage behaviour rather than ‘as required’ medication. This was evidenced in Medication Administration Recording sheets. Medication was seen to be stored on a shelf in the food fridge. It was recommended that they should be stored there in a separate and labelled box. Third Avenue (7/9) DS0000018078.V327354.R01.S.doc Version 5.2 Page 15 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 home has a complaints procedure and each service user has a service users guide that highlights the complaints procedure. The homes policy and procedures and training of staff generally protect residents from abuse. EVIDENCE: Estuary has established policies and procedures relating to complaints. Since the last inspection there have been no complaints received by the home or reported to the commission. All residents have a user-friendly complaints guide in place. A pictorial poster explaining who to raise any worries or concerns with was displayed in both the hall and the office. No referrals regarding 7/9 Third Avenue had been made under POVA (protection of vulnerable adults) since the last inspection. The training matrix informed that most of the permanent staff and contracted agency staff have up to date training in the protection of vulnerable adults and training in positive responses or management of challenging behaviour, a relevant issue at Third Avenue. There was a lack of evidence of training on these subjects in relation to other agency staff, and although copies of training records were provided for several staff, they were not all clearly stamped. The more long-term permanent staff spoken with were clear on action to take and reporting procedures to protect residents. Some newer staff that have not yet had current training were not as confident. Estuary had not yet rewritten the whistleblowing procedure for staff in clearer language as recommended previously. Third Avenue (7/9) DS0000018078.V327354.R01.S.doc Version 5.2 Page 16 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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises were warm, clean, well furnished and maintained and provided residents with a safe, comfortable and appropriately equipped environment to meet their needs. EVIDENCE: On the day of the site visit the home was observed to be clean, odour free and no health and safety issues were highlighted. Warning signs were observed on outward opening doors, following risk assessment. Of those individual residents rooms inspected, all were observed to be personalised and distinctive with their personal effects and were reflective of resident’s hobbies and interests. Communal rooms were also comfortably furnished and well decorated. The accessible garden was well maintained. Corridors had recently been redecorated. The cooker hob on one of the units was out of order but it was confirmed that another was ordered and due to arrive in the near future. Cooking for all was being undertaken in the other kitchen and though not an ideal situation, safety procedures were in place in relation to transporting it. Third Avenue (7/9) DS0000018078.V327354.R01.S.doc Version 5.2 Page 17 The registered manager advised that a conservatory is to be added to the home for extra space, as part of the planned recognition that residents will need more equipment as they get older. Each of the houses contained their own assisted bathroom and separate toilets. The registered manager advised that all residents have been assessed for new seating. Staff advised that four residents use a wheelchair on a permanent basis and that the home has the appropriate hoists and that there is a hoist available at each end of the building. Staff also confirmed that there are specialist slings for individual residents that meet their individual needs, for example different ones for transfers than for bathing. Bathrooms displayed instructions on the use of individual and specific slings. The laundry was clean and well organised. It contained a list of the colour of the towels belonging to each individual resident. A sewing stitch in this colour was also discreetly placed in each resident’s clothing to ensure that they only received their own clothes. Third Avenue (7/9) DS0000018078.V327354.R01.S.doc Version 5.2 Page 18 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. Observation at the site visit indicated that residents are offered positive relationships with staff. A review of the staffing levels could ensure best outcomes for residents. Staff recruitment did not best safeguard residents. Staff training and knowledge generally supported residents but this was not so clearly evidenced for some agency staff. EVIDENCE: Regular staff spoken with were clearly able to show that they knew the individual residents ways and personalities and that their communications and responses were consistently interpreted. They were also able to show that they knew the contents of the care plans and explain how these were used every day. The observed interactions between staff and residents were relaxed, positive and respectful. The pre-inspection questionnaire advised that five of the six permanent staff and two of the contracted agency staff had achieved NVQ level 2 or above. Additional staffing hours have been provided to support one resident following the loss of their day resource. This continues to need review for two additional residents who have had reduced resource input, and as noted in the last Third Avenue (7/9) DS0000018078.V327354.R01.S.doc Version 5.2 Page 19 inspection report also needs to take account of the increased needs of residents over the 13 year period that the home has been open. 7/9 Third Avenue has been able to attract two new permanent staff since the last inspection, which is positive. Recruitment files show that the application form does not contain a declaration of health or offences. Both files contained evidence that appropriate references and criminal record bureau checks were obtained prior to employment commencing. Both files contained photographs and appropriate evidence of identity. To assist with continuity of care for residents, Estuary had contracted six agency staff to work routinely as part of the team. Other agency staff were also used as evidenced in the roster and on the day of the inspection. The recruitment files for new staff contained a record of induction. Training records for these and three other permanent staff evidenced an appropriate range of mandatory training was planned or had occurred. In addition staff had attended recent training relating to service uses specific issues such as Helping Residents to Express Themselves, Obsessive Compulsive Disorder, or Working Effectively with Asperger’s Syndrome. Records confirming that appropriate references and checks were in place relating to all agency staff were not available. As advised in the last inspection report, written confirmation of this needs to be obtained by the home from the agency in relation to each individual staff member prior to them working their first shift at the home. This matter will be addressed separately with Estuary. It was advised that the agency will not provide staff with copies of training certificates, however it would be appropriate for the home to obtain copies of the training record provided for each staff that evidences up-to-date training has occurred. Third Avenue (7/9) DS0000018078.V327354.R01.S.doc Version 5.2 Page 20 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, 38, 39, 41, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management systems are good and the home is run in the best interests of residents. There is evidence to show that the manager and staff work together as a team to develop the service and improve the standards of care for residents. No health and safety concerns were identified. EVIDENCE: The registered manager has ample managerial experience in the caring profession and, together with the staff team, ensures that residents benefit from a well-run home. Staff spoken with found the manager supportive. There were clear systems in place in the home to achieve positive outcomes. Information submitted on the pre- inspection questionnaire and records in the home, showed that services and equipment had been regularly checked and maintained by approved contractors. Third Avenue (7/9) DS0000018078.V327354.R01.S.doc Version 5.2 Page 21 The registered provider has not undertaken the required monthly visits to the home and the last report available was dated May 2006. Estuary operate a Quality Network group that included 7/9 Third Avenue in its most recent quality network review. A copy of the report of this audit was provided. Objectives of the action plan included supporting residents to be essential participants of Estuary s recruitment policy and procedure. The manager advised that internal audits are undertaken which include 82 separate checks weekly between the two houses, relating for example to medication money or bedroom temperatures. It was not possible to inspect and fully audit all records relating to resident’s money. Records were available of resident’s weekly expenditure and a group rolling float. Receipts are sent Estuary each week and therefore could not be confirmed. It was noted positively that residents are no longer purchasing/ being charged the same amount for toiletries and the records showed that they are purchasing individual items. Records sampled indicated that residents money was being used appropriately, for example in relation to toiletries, for swimming club and attending social activities such as shows. Inspection of fire drill records indicated that they are carried out monthly and that all staff are included. Weekly records were available relating to checking the fire alarm, exits, blankets, extinguishers, detectors, emergency lighting and hot and cold water outlets. Control of substances hazardous to health (COSHH) items were safely stored. Theses were the only aspects of this standard assessed. No health and safety concerns were observed. Third Avenue (7/9) DS0000018078.V327354.R01.S.doc Version 5.2 Page 22 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 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 2 X 3 3 x Third Avenue (7/9) DS0000018078.V327354.R01.S.doc Version 5.2 Page 23 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 YA1 Regulation 4&5 Requirement The service user guide must be amended to reflect the changes in regulation and include the required information The person registered must ensure that residents have adequate opportunity for community presence and leisure pastimes with adequate staffing support levels. Previous timescale 01/03/06 not met. The person registered must ensure that residents have adequate opportunity for community presence and leisure pastimes with adequate staffing support levels. Previous timescale 01/03/06 not met. 4 YA24 23(2)p The person registered must ensure the provision of a working cooker in each kitchen. The person registered must ensure that there are sufficient staffing levels to provide DS0000018078.V327354.R01.S.doc Timescale for action 01/03/07 2. YA13 16(2) m&n 01/03/07 3. YA14 16(2) m&n 01/03/07 01/01/07 5. YA33 18(1)a 01/03/07 Third Avenue (7/9) Version 5.2 Page 24 6. YA34 residents with adequate opportunity for community presence and leisure pastimes. (please also refer to Standards 12 and 13 above) 17(2)Sch4 The person registered must (6) maintain in the care home all the records required for all staff, including agency staff. (Previous timescales from 02/09/04, 02/03/05, 01/10/05 and 10/01/06 not met). 19 Sch 2 05/12/06 7. YA34 8. YA35 18(1)c(i) 13(5) Staff application/recruitment files 05/12/06 must contain a declaration of the persons physical and mental health in relation to the work they are to perform. The person registered must 01/02/07 ensure that evidence of up-todate training/qualifications is available for all agency staff. (Previous timescale from 01/02/06 not met). The person registered must ensure that visits and reports as required by regulation are undertaken monthly and available in the home for inspection 01/02/07 8. YA39 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. 2. Refer to Standard YA20 YA23 Good Practice Recommendations Service users medication should be stored in a separate and labelled container if kept in the kitchen fridge. The whistleblowing policy should be written in plain language. DS0000018078.V327354.R01.S.doc Version 5.2 Page 25 Third Avenue (7/9) Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Third Avenue (7/9) DS0000018078.V327354.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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