Inspection on 27/09/06 for 7a Taylor Road

This inspection was carried out on 27th September 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

7a Taylor Road 01/11/05

7a Taylor Road 27/01/05

7a Taylor Road 29/09/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 7a Taylor Road West Earlham Norwich Norfolk NR5 8LZ Lead Inspector Mrs Lella Andrews Unannounced Inspection 27th September 2006 01:30 7a Taylor Road DS0000027528.V314634.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 7a Taylor Road DS0000027528.V314634.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. 7a Taylor Road DS0000027528.V314634.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 7a Taylor Road Address West Earlham Norwich Norfolk NR5 8LZ 01603 259916 01603 259940 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) www.efitzroy.org.uk Elizabeth Fitzroy Support Miss Carolyn Peacock Care Home 7 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (4), Physical disability (2) of places 7a Taylor Road DS0000027528.V314634.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 2005 Brief Description of the Service: 7a Taylor Road is a residential care home providing personal care and accommodation to seven people with a learning disability. It is a detached chalet bungalow that operates as two units within the home and provides mainly ground and some first floor accommodation that is accessed by a passenger lift or the stairs. There are seven, single bedrooms with washbasin and in each unit there is communal use of a lounge, dining area, kitchen, two toilets, a bathroom and in one unit an additional shower room. The home has a small-enclosed garden to the front and rear of the property and there is roadside parking to the front. It is situated on a residential housing estate in Norwich close to local shops and health amenities and the home provides both in-house day care and access to a range of community based activities and day care provision in Norwich. 7a Taylor Road DS0000027528.V314634.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection, taking place over 7 plus hours and two days, due to the absence of the Manager and her Deputy on the first day. There were seven residents living in the home. Preparation had taken place in the CSCI office and there was a completed Pre-Inspection Question. Policies and records were examined and a tour of the premises undertaken. The Commission had also sent out survey forms to be distributed by the Home to the residents, their relatives and healthcare professionals. Completed forms with staff support had been received from two residents, seven forms had been received from residents’ relatives, two of whom were spoken to on the telephone together with one form from a healthcare professional and their views have been taken into account in this report. Concerns received at the CSCI regarding the night staffing of the home were taken into account as part of the inspection. Five residents were seen, but conversation was limited for four of the residents. Three members of staff were spoken to in private. What the service does well: What has improved since the last inspection? • • • The medication administration records are being completed appropriately. Photographs are held on staff files, except one. There is a new quality assurance system in place, ensuring that the opinions of everyone, from residents, visitors/relatives, other DS0000027528.V314634.R01.S.doc Version 5.2 Page 6 7a Taylor Road • • • • professionals and staff are sought on the standard of care and service provided in the Home. Residents wishes for arrangements at death are being sought to be recorded in their care plans. Carpets have been replaced in the home. Arrangements are being made to make the CSCI Reports available to relatives and visitors to the home. There are two new TVs in the lounges and further new furniture had been ordered. What they could do better: • • • • • • Staffing levels, particularly at night, and the management of challenging behaviour needs to be continuously monitored. There should be continuing monitoring of residents’ changing needs, particularly those which are age related. The proposed development of care plans in Makaton symbols would be good practice. The further decoration of the home and the renovation of the back garden need continuing attention. Checks on the state of repair of furniture in residents’ rooms should continue to be carried out. The size of the budget for food in the home should be monitored to ensure that residents continue to receive a good quality diet, according to their specialised needs, also the proposed food folders with Makaton symbols, recognisable by residents would also be good practice. Two-way staff communication with the wider organisation could be improved, as well as the Home’s communication with relatives. Consideration should be given to relatives wishing to see their relatives in private. Relatives should be made aware of the Home’s complaints procedure Review of the procedures for maintenance of equipment, especially that in the laundry room should be undertaken. • • • • 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. 7a Taylor Road DS0000027528.V314634.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 7a Taylor Road DS0000027528.V314634.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. People, who use this service, and their representatives, have good information about the home in order to make an informed decision about whether the service is right for them. The person centred needs assessment means that peoples’ diverse needs are identified and planned for before they move to the home. EVIDENCE: There had been no new admissions since the last inspection, but the records seen showed that assessments were completed prior to admission, together with information from the residents, their relatives, their families/representatives and other healthcare professionals were sought to ensure that the needs of the residents were identified as being able to be met by the Home. There were also opportunities for residents, their relatives/representatives to visit the Home prior to admission and the Manager described the admission of two residents who were friends and who came on various visits and eventually on a month’s test drive of the Home, before permanent decisions were made. Care Plans seen contained agreements and Terms and Conditions 7a Taylor Road DS0000027528.V314634.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are well set out in an individual, person centred care plan consultation with the resident and relatives, if appropriate. The proposed development of care plans in Makaton symbols would be good practice. EVIDENCE: All the residents seen were well looked after. Four care plans examined revealed personal health and social care information, food charts, nutrition, support plans, routines, needs assessment, professional guidance, exceptional reports, medical appointments, personalised support, risk assessments, reviews and a photograph of the resident. Daily records gave good accounts of how residents were, whether they had had visitors or taken part in activities. There was evidence that residents were consulted and had taken part in reviews. It was observed over the two days and demonstrated from records that residents were consulted on their daily activities, given choice, were protected and that their confidentiality was maintained. The six relatives’ 7a Taylor Road DS0000027528.V314634.R01.S.doc Version 5.2 Page 10 surveys confirmed that they were satisfied with the care given to their relatives in the home, as did the healthcare professional. Residents’ money was checked at random and found to be correct. Management of risks were mainly to minimise risks resulting from certain behaviours, and took into account the age and the specialist needs of the residents, but there were detailed guidelines for staff on interpreting certain residents’ means of communication, verbal and non-verbal. The Manager said that it was the Home’s intention to develop care plans in Makaton symbols, so as to provide more participation for residents. There is therefore a recommendation that this should be followed through as good practice. 7a Taylor Road DS0000027528.V314634.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15, 16,17 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Opportunities are provided for activities in the community for those residents who are well enough and the Home encourages the maintenance of relationships and variation of in-house activities and meal planning, as far as is possible, with residents. EVIDENCE: Activities are planned very much on an individual basis, according to age, the preferences of residents and their health. It has to be borne in mind that there are six residents in the home aged over 60, but from the quality assurance survey recently undertaken in August the investigation and development of resident involvement in local community events appears in the action plan. One resident spoken to indicated that she had been horseriding and swimming, with the Community Services Team, which she enjoyed. She has day care outside the home five days a week. One resident dislikes going out and another enjoys social activities, according to her keyworker. There are videos and CDs available in both ‘sides’ of the house. 7a Taylor Road DS0000027528.V314634.R01.S.doc Version 5.2 Page 12 The staff spoke of the work with residents to support them in their personal development, behavioural management and in maintaining friends and relationships. When it is possible, residents are able to go shopping with staff and to help with domestic tasks in the home, such as folding laundry, or putting shopping away. They encourage each resident to be as independent as possible and to make choices, whilst ensuring that the rights of each resident are promoted and protected within the group. Residents are encouraged to maintain relationships with family and friends and the six residents’ surveys received revealed these connections. However, three of the surveys commented that, because of the domestic nature of the Home, i.e. two small housing units, there is no room available for meeting with their relative privately. There is therefore a recommendation that consideration should be given to providing some privacy for visiting relatives. Staff reported that menus for meals are agreed with residents before shopping. The residents’ nutrition requirements are individually considered and are varied. One has a diabetic diet and has the input of a Dietician, another goes for several days without wishing to eat and another has a specific regime and favourite foods are noted in care plans. Several residents are prescribed food supplements, but concern was expressed by members of staff that they felt the budget allocated for food shopping has remained unchanged for several years and they are required to undertake this shopping, mostly from a prescribed list, with little fresh vegetables and fruit, and to prepare food in the two kitchens. The manager reported that everyone’s food intake is monitored, there is always a petty cash budget for anything extra. However, there is a recommendation that the wider organisation examines the food budget, together with the organisation of and choice at meal times, as there is no designated cook. The manager reported that she hoped to use her training in Makaton to develop food folders for individual residents with Makaton symbols to offer more real choice for residents, which would be good practice. 7a Taylor Road DS0000027528.V314634.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 21 and 20 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Residents receive appropriate personal support provided in a private and dignified way and have access to other healthcare support when necessary. There are arrangements for the safe storage and administration of medicines, which protect residents and records of the wishes of the residents in the event of their death are being compiled. EVIDENCE: It was observed that residents are assisted with decision making and the three staff spoken to said that they assist the seven residents with limited communication skills by understanding their response to questions and preferred manner of communication, using simple sign language, pictures and observation. The manager, as at the last inspection, said she was gradually working with each resident and staff members to agree and arrange a funeral plan for each resident. The two individual person centred plans examined on the first day of the inspection contained information on first person accounts of a lifestyle plan, means of communication, likes and dislikes, interests, worst day prompts, routines, health care instructions, management of challenging behaviour and 7a Taylor Road DS0000027528.V314634.R01.S.doc Version 5.2 Page 14 exceptional events, such admissions to hospital and aftercare and reviews. They also showed the involvement of each resident, staff and other professionals and it was observed on the day that the delivery of care was flexible, varied and unhurried, according to the individual requirements of the residents. The survey from the healthcare professional showed satisfaction with the care given in the home to all the residents. However, there were comments from relatives that they would wish to be involved in their relative’s annual reviews, as used to be the case two years ago. Although they accept that the difficulty with this does not necessarily lie with the Home, there is, nevertheless, a recommendation that those relatives, who wish, and where appropriate, should be involved in some reviews of residents’ care at least annually. Those residents, who are fit and well enough, are encouraged in participating in activities and attention is given to treating individuals with respect and dignity. Staff spoken to and records provided evidence that staff had undertaken training in medication administration, medication was stored correctly and policies and procedures were held, which staff were required to read and sign. The MAR sheets showed that medication records were now being completed correctly, which was a requirement from the previous inspection. This was later confirmed by the Manager. 7a Taylor Road DS0000027528.V314634.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The quality outcome in this area is good. This judgement is made using the evidence available including a visit to this service. The Home has active policies and procedures for dealing with concerns and with the protection of vulnerable adults, backed by staff training; however, residents’ relatives should be made aware of the complaints procedure, in order to further protect residents. EVIDENCE: The Home has a complaints policy and the procedure is displayed in the Hall, and no formal complaints had been made to the Home. Two areas of concern had come to the notice of the CSCI regarding night staffing levels and the aftercare of residents on discharge from hospital. Records seen, together with a discussion with staff and the manager, demonstrated that the appropriate action had been taken by the home in the areas of concern, although there is a requirement under Staffing in this report. Two residents’ surveys returned demonstrated that residents knew to whom they should complain, but six of the seven relatives’ surveys returned said they were not aware of the Home’s complaints procedure, although they had no grounds for complaint and at least two of them visited on a regular basis. There is therefore a recommendation that all residents’ relatives should be made aware of the complaints procedure. The three members of staff spoken to and the staff files examined showed that they all had knowledge of protection of vulnerable adults issues and had received training in the management of challenging behaviour and the protection of vulnerable adults. 7a Taylor Road DS0000027528.V314634.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 The quality outcome in this area was adequate. This judgement has been made using the evidence available including a visit to this service. The Home provides a safe and homely place to live with a friendly atmosphere, however, there are still areas which require attention, over several inspections. EVIDENCE: There have been improvements since the last inspection, new carpets have been laid and there have been two new TVs and the Manager said that other furniture, such as a sofa and a cupboard have been ordered. The two units, which are purpose built are domestic in nature and fit for purpose, and on the day the Home was clean, odour free and well-decorated in most areas and furnished to a good standard. However, residents’ relatives’ surveys revealed that it was felt that some areas of the home were shabby and there are still areas requiring decorating. The Manager has the paint ready for this, but as the staff are required to do this, this is still outstanding and there is a repeated recommendation for the third time for this to be done. The Manager has asked for quotations elsewhere for this to be completed. All the residents’ rooms seen during a tour of the building were personalised and a cat brought by one of the residents makes for a homely atmosphere for 7a Taylor Road DS0000027528.V314634.R01.S.doc Version 5.2 Page 17 those who like animals. However, in one room there was a unit with drawer fronts hanging off, which a member of staff explained were going to be replaced after some weeks of being in this state. There is therefore a recommendation that regular audits of residents’ rooms are carried out to ensure that all furniture is fit for purpose. Outside, the front garden had been redesigned with volunteer assistance, but the back garden, which is a difficult area, being steeply raked and the original planting lost, rising up from a paved area close to the house, is very overgrown with brambles and weeds and does not provide a pleasant outlook for residents. The Manager has recruited the services of a volunteer to make pots and containers for residents to see from their rooms, but there is a recommendation that there should be a review of the landscaping of the back garden area for the benefit of residents. The laundry room contains the washing machine and sluicing facilities to aid in the protection of the health and safety of all residents and staff, but a member of staff explained that the tumble dryer had recently broken and it had taken 48 hours for it to be in operation again, this, together with the incidents of two fires related to washing machines is dealt with elsewhere in this Report. 7a Taylor Road DS0000027528.V314634.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 The quality outcome in this area is adequate. This judgement has been made using the available evidence including a visit to this service. Staff members are competent, the procedure for recruitment and opportunities for training provide safeguards for residents, but reviews of staffing levels related to residents’ changing needs would further protect those living in the Home. EVIDENCE: Residents were seen to be well cared for and this was confirmed by all the residents’ relatives’ surveys. Staff files provided evidence of induction training, training in medication and challenging behaviour. Staff spoke of supervision with the manager or deputy manager and the records provided evidence of this. There were handovers and staff meetings, and the Minutes circulated to members of staff who could not attend. The Manager reported that there were 4 members of staff with NVQ and 3 working towards it and in future Makaton training would be included in the induction training for new staff. Recruitment procedures were seen to be robust and staff files contained the necessary CRB checks, references, personal details and proof of identity of each staff member. However, it was disappointing that despite a requirement in the last inspection for photos of staff to appear on each file, this was not 7a Taylor Road DS0000027528.V314634.R01.S.doc Version 5.2 Page 19 found to be the case in one instance and this requirement is therefore repeated. Staff spoken to said that they enjoyed their work but in some cases were very aware of the changing needs of particular residents, together with their loss of independence. They spoke of the particular night shift patterns of sleep-ins, preceded by a late shift and followed by working the next day, which was not very satisfactory, should their sleep be interrupted. This had recently been an issue with two residents, one discharged from hospital and another disturbed in the night, and the Manager reported that a log was being kept of sleep in patterns and that negotiations were to take place concerning and increase of staffing during the day, although there is 1:1 funding for some residents. There is considerable use of agency staff, which was observed on the first day of inspection, this puts extra pressure on existing staff, since agency staff, new to the home, cannot be expected to know the residents, or to be able to communicate with them effectively. There is therefore a requirement to support this review of staffing, both at night, including the night sleep in rotas, and during the day, according to the residents’ fluctuating and changing needs. 7a Taylor Road DS0000027528.V314634.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The quality outcome in this area is good. This judgement has been made using the evidence available, including a visit to the service. The manager is supported by a deputy manager, as well as the management of the wider organisation, to give leadership and direction to staff to ensure that residents receive a good standard of service. EVIDENCE: The Manager has been in post for over 5 years. She is a qualified nurse who has past experience of working with those with a learning disability and complex needs. She has completed training in management, health and social care and the MVQ Registered Manager award. She has recently completed a course in Makaton and described good ideas of putting this into practice, as described elsewhere in this Report. She has the support of the wider organisation; the Operations Manager visits every other week and the necessary Reports have been received by the CSCI. 7a Taylor Road DS0000027528.V314634.R01.S.doc Version 5.2 Page 21 The Manager is an NVQ Assessor, as well as the Deputy Manager who has just started training together with another staff member. Policies and procedures are in place dealing with all aspects of the service and a quality assurance process has been set in motion examining Standards, one monthly, a copy of which has been received in the CSCI office, which should further ensure that the service is run in the best interests of the residents. Health and Safety records were examined and found to be in order, but there is a requirement that a review of the procedures for repairs and maintenance of electrical equipment should take place to ensure that infection control measures are not adversely affected by breakdowns, particularly in the laundry. Records showed that there had been two minor electrical fires caused by washing machines a year apart. 7a Taylor Road DS0000027528.V314634.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 2 X 7a Taylor Road DS0000027528.V314634.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 YA34 Regulation 19.1.a.b schedule 2 18 (1)(a) Requirement The registered person must ensure that each staff file contains a photograph of the staff member. This is a repeated requirement. The registered person must ensure the numbers of staff on duty, day or night, meet the individual and collective needs of service users (in this case continuous review of the fluctuating, changing needs of residents). The registered person must ensure the health and safety of service users and staff, including the maintenance of electrical equipment (in this case a review of the procedure for repairs and maintenance of equipment in the laundry). Timescale for action 01/11/06 2. YA33 01/11/06 3 YA42 13 (4)(a) 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. 7a Taylor Road DS0000027528.V314634.R01.S.doc Version 5.2 Page 24 No. 1. Refer to Standard YA24 Good Practice Recommendations It is recommended that the redecoration of the remaining walls, where the decoration is worn, be continued to make all areas of the home attractive for residents. Repeated recommendation for third time. It is recommended that the Home continues to develop care plans in Makaton symbols to ensure further resident Participation. It is recommended that consideration be given to providing some privacy for residents and their visiting relatives. It is recommended that the wider organisation examine the food budget, together with the organisation of and choice at meal times for a healthy diet. It is recommended that the Manager’s idea to develop food folders for individual residents with Makaton symbols be carried through to offer more real choice of food for residents. It is recommended that subject to the resident’s consent, relatives who wish should be involved in some reviews of residents’ care, at least annually. It is recommended that all residents’ relatives should be made aware of the Home’s complaints procedure. It is recommended that all residents’ bedrooms should be audited on a regular basis to ascertain that the contents are fit for purpose. It is recommended that there should be a review of the landscaping of the back garden area to make it more attractive for residents. 2. 3. 4. 5. YA6 YA16 YA17 YA17 6. 7. 8. 9. YA18 YA22 YA25 YA24 7a Taylor Road DS0000027528.V314634.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 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 7a Taylor Road DS0000027528.V314634.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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