Inspection on 16/03/06 for 85 Drove Road

This inspection was carried out on 16th March 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

85 Drove Road 19/10/06

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Drove Road (85) 85 Drove Road Swindon Wiltshire SN1 3AE Lead Inspector Stuart Barnes Announced Inspection 16th March 2006 09:30 Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 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 Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 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. Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Drove Road (85) Address 85 Drove Road Swindon Wiltshire SN1 3AE 01793 635560 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) Community Access Network Mrs Tracey Lynne Parker Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The registered manager must work a minimum of 64 hours per four week in the home except when absent due to sickness, training or annual leave. The company must ensure that the kitchen area within this care home must be upgraded to include new cabinets and any other necessary equipment needed Any such upgrade must be completed by 1 September 2006 and should take into account the recommendation made by Mr Jamie Meeking, Environmental Health Officer of Swindon Borough Council in his report dated 6 May 2005, and meet with his approval. First inspection Date of last inspection Brief Description of the Service: 85 Drove Road is a small sized care home for up to 3 people aged between 18 and 65 years of age who have a learning disability. A company called Community Access Network (C.A.N.) operates the home. C.A.N. have 3 other similar services in Swindon and North Wiltshire. The home opened at the end of 2005 after the company decided to sell an existing nearby home that at the time did not meet the relevant National Minimum Standards (NMS). Consequently all current service users and staff transferred to this house. Service users were actively involved in choosing the accommodation and deciding the decoration and furnishings. The house is a 3 bedroom, two-storey semi detached property and is located on a busy main road, within a 10 minute walk of Swindon town centre. It provides all service users with a spacious bedroom. Additionally there is a large L-shaped lounge/ dining room and a spacious kitchen that has been recently refurbished as well as two bathrooms. Parking is very limited. The service replicates principles of ordinary living and is typically staffed by one person on duty with an additional person at busy times. At night time there is no awake staff presence. Instead staff take in turns to sleep in on a rotational basis. Sleep in staff are expected to meet any night time needs as they arise. The main service aims are to provide high quality care within the community, where people are supported to take informed risks and promote opportunity. Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was by appointment and it is the first inspection of this service since it was registered as a care home. It was undertaken by one inspector and took approximately 7¼ hours. In carrying out the inspection the manager was requested to provide a range of pre-inspection information. The inspector spent time with the manager examining various policies, procedures and practices. Time was also spent talking to the staff on duty and interviewing two of them in private. With the consent of the occupants two bedrooms were seen. Time was also spent talking informally and meeting in private with the people who live at the home. Their views have informed this report. In total 31 out of 43 National Minimum Standards were inspected. The service is well managed. What the service does well: What has improved since the last inspection? What they could do better: Part of the accommodation has cold spots in the winter months. The refurbishment programme needs to be completed. Some paintwork would benefit from a more thorough clean. Care needs to be taken to ensure all job applicants provide details of all past employment. Policies in respect of infection control and managing physical interventions/restraint need to be updated to reflect recent changes in best practice. Care needs to be taken that fire safety checks are carried out every week. Where service users do not respond appropriately to a fire alarm sounding, consideration should be given as to what can be done within a risk assessment framework. Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 Page 6 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. Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 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 Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 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): 1, 2, 3, 5. The company provides comprehensive information about the service that has both breadth and depth. This home continues to support and guide service users very effectively so that they can benefit from living at the home and access a range of work, leisure and health facilities. The needs of current service users appears well met. EVIDENCE: The current statement of purpose and service user guide was examined and it meets the required standard. Information is both comprehensive and presented in an easy to understand format. Service users confirmed they are provided with their own service user guide, which includes their views of the service, key contract terms and the complaints process. These documents also describe the service provided and the terms and condition of residency. They include house rules and expectations. They promote empowerment, dignity, choice and independence in a manner that is clear and unambiguous. A reassuring feature for families is that the assessment documentation is good at validating separate and distinctive viewpoints of respective family members. Kinship is promoted and encouraged. Documentation in respect of all the case files was examined and the standard of case files documentation is very high. Service users confirm that they involved in the assessment and review process. Care managers and service users also sign assessment documentation as a means of promoting the joint management of the risk. One service user spoke about the help they get as a Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 Page 9 result of them having difficulty in a specific area of concern. Case documentation also confirms progress made. For example; one file highlighted progress made in behaviour and spoke about many positive changes since the last review. Service users confirm that they are supported to access a range of health care provision including, where appropriate, services such as dental care, eye testing and chiropody. All current case files include written terms and conditions of residency/service contract. They outline the services to be provided, any obligations placed on each service user and the arrangements for the payment of fees and costs. It is company policy to confirm in writing the extent to which the service can meet a persons needs, once they have been assessed for a place. A copy of these letters were on file. Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, These are areas where the service is achieving success and is reaching high standards. There is a good balance between the promotion of rights, responsibilities and independence. EVIDENCE: Care planning is person centred and covers 10 key areas, including, communication, family contact, health care as well as work and leisure. Restrictions (if any) on choice, freedom or facilities are transparent. Case documentation shows that they are explained and agreed. For example; service users must agree to share household tasks, not to smoke in bedrooms, to pay for any deliberate damage and to have no overnight visitors without permission. There is evidence of collaborative and systematic working with other key health/social care workers. Service users confirm they are actively involved in the planning of their care and they convey an ownership of their plan. It can be seen that certain challenges and behaviours are being well managed openly and constructively inline with the homes main aims. Service users are encouraged to make decisions and to take responsibility for them. The inspector observed a support worker guide a person through a difficult choice enabling the person to consider the consequences of spending money. Another example includes supporting a service user to safely visit the Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 Page 11 local town centre. Service users confirm that they are involved in making decisions about how they spend their day, where they go for leisure or entertainment and how they travel. They also confirm that they attend meetings where decisions are taken about them. Service users also assist with the recruitment of staff. They told the inspector that they are involved in deciding what holidays they can go on, choosing the decoration of the lounge area and meal options. Monthly house meetings are routinely arranged between service users and a member of the staff. Records of these meetings show that while a wide range of issues are discussed such as fire safety, house cleaning and trips out the agenda shows a hint of being somewhat repetitive. This needs to be guarded against. Another area managed very well is the way the service manages any monies held on behalf of residents. This includes thorough daily checks of each person account and balance. Service users are provided with a key for their room and to the entrance door, if they want one. They were observed to answer incoming phone calls to the home. It can be seen that the written care plans guide staff to focus on positive outcomes. For example; in one plan the support staff are reminded to give a service user time to express themselves. For another person guidance is given to staff stating that if the person does not comply with a request to give the service user more for time to reflect on their responsibilities. Service users also keep a written daily diary in which they can record how they spent their day and other view points. These diaries show that people exercise their options to make decisions or not as the case may be. The whole ethos of the service is to support service users to manage personal risk taking. The service aims support this and on the whole it is well done. This is underpinned by an effective key worker system and the maintenance of clear and effective records that allow for regularl and critical review and update where necessary. The assessment and management of risk is generally very well managed. Records show each person’s risk elements are individually assessed and link with each person’s service plan. There is a detailed fire safety risk assessment in place as well as a generic risk assessment for the facilities and property. There is a good balance between ensuring personal safety and encouraging personal development. However not all risk assessment detail the next intended date for review. Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 These are areas where the service is achieving success and reaching good overall standards. Meal arrangements allow for choice and promote life skills. EVIDENCE: Service users report good satisfaction levels. Placement reviews indicate progress in many areas, such as with personal development, social skills and managing behaviour. For example, two case files show good progress with people controlling their temper/feelings and with their participation in the wider community. Positive outcomes are recorded in all case files. Training for independence is integrated within personal responsibility programmes as well as part of routine daily living. However some case documentation points to a greater emphasis being placed on competency with domestic arrangements than wider skill or personal development. One service user spoke about how he had tried to find some paid work and how this had been difficult for them to maintain. Risk assessments link to personal development goals and personal aspirations. Another service user told the inspector how they are now taking more care with their room now they have a bigger room. Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 Page 13 All service users are encouraged to use their daytime usefully and in a beneficial way. It was observed that staff work hard to keep people focussed and on track. This is typically done by the use of praise including written praise in daily diaries, which service users read, the use of gentle prompts or having discrete chats to examine difficulties. Sometimes more formal agreements and understandings are made. The service is well placed for easy access to a whole range of leisure and education facilities. Service users confirm that they can and do access pubs, clubs, sports facilities, theme parks and civic amenities. Records show that service users go from time to time to a variety of individually selected activities such as discos, the local theatre, snooker or speedway. One service user confirmed they go to the theatre, attends discrete drop in centres and sports facilities. Service users confirm that they are encouraged to maintain hobbies and interest citing gardening, computer work and attending speedway as 3 current examples. Case documentation shows that two people are actively supported to access their friends or family. People are supported to have individually planned holidays of their choosing and the necessary staff support is provided. The service user guide shows that friends and relatives are welcome to visit. Service users confirmed that this was so. Menus were seen. Service users report that they choose the menu for one week in rotation and the person choosing the menu also does the required shopping. By having a system where support staff will occasionally take responsibility for planning a meal to extend the culinary experience for residents, the service has found a good way of introducing new menu options. For example, one support worker prepared beef in oyster sauce. Each day a different service user is supported to prepare and cook the main meal. Lunch tends to be a snack. Service users confirm that breakfast is a free choice and the main meal is at night time. Puddings are not normally provided in the week but are offered at weekends as a ‘treat.’ The manager said this was a successful way to ensure healthier eating. No service user made any negative comment about the meal arrangements and one said they liked the food provided and that it was a good idea to share the cooking as it helped them to be more independent. Another feature is that each service user has there own fruit bowl kept in the kitchen that they can access at anytime. A strong feature of the service is the way it seeks to promote citizenship and protect individual rights through its service objectives, care planning and in the delivery of the service. Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Service users are supported to access a range of medical services and specialist needs. Staff encourage service users in a discrete and effective way to have healthy lifestyles. EVIDENCE: Case files show that each service user is supported to access any medical services required including specialist services where needed. Service users report progress in their well being. One told the inspector of the support they received from the staff to “loose weight and to keep it off.” Another service user spoke about the help they get to deal with difficult feelings they have. There is documentation that confirms each service is supported to obtain an annual medical check up including a yearly medication review. Support staff promote options for healthy living; often discretely but also by design. For example people will walk to the shops rather than use the car. Support staff makes adjustments to menu’s chosen by service users. Guidance and prompts are given about unhealthy eating, smoking or drinking to ensure these are appropriately moderated, if needed. Communication systems provide options for weekly review and ‘one to one’ support. Support staff show a good understanding of mood and emotional well being. They demonstrate that both intuitively and in a measured way they are able to manage excess highs and lows. There are written reports that confirm that the support staff take forward appropriate concerns in managed way. Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 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. No complaints have been made about this home, since it was first registered. Systems in place appear to be effective at protecting service users from harm EVIDENCE: The company has a detailed policy on complaints and on protecting service users from abuse. The manager has working knowledge of using the local system for reporting disclosure of abuse and dealing with any such allegations. Support staff impress as people who would report any concerns they may have. The complaints procedure sets out three stages for responding to a complaint. Details are included in the service user guide. Records show the home has received no complaints since it opened. Discussion with service users confirmed they were happy living at the home and felt supported by the staff. Copies of Wiltshire and Swindon “no secrets” guidance for staff was available in the home. Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 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, 25, 26, 27, 30. Service users living at 85 Drove Road like the house. Many improvements have been made since the home was opened but they are not yet finished. EVIDENCE: The home is ideally situated being in walking distance from Swindon town centre with its range of shops and civic amenities. A feature of this inspection is that service users all confirmed how much better this house is to the one they previously used as a care home. Some aspects of the accommodation however do not meet all the required standards for a recently registered care home. It is accepted by the Commission provision of these as a condition of registration would detract from providing an ‘ordinary living’ experience. These deficits are considered marginal and do not significantly detract from having suitable accommodation. Each service user has their own bedroom, two of which are very spacious. Bedrooms do not provide wash hand basins. All bedrooms were highly personalised reflecting the personalities of those who use them. There are two bathrooms/shower facilities instead of each service user having ensuite facilities. Since the home opened many areas have been redecorated and some partial refurbishment has taken palace. Service users confirm that they were actively involved in choosing the house and in deciding some of the decorations and furnishings. Some redecorations of rooms were not fully Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 Page 17 completed. It was noticed that there were a couple of cold spots in the home, which the manager was aware of and has plans to remedy. At the time of inspection the kitchen had only been partially refurbished and was awaiting further redecoration and worktops, which were on order. While tidy and generally clean there were some paintwork i.e. radiators, doors and skirting which would benefit from a more thorough clean and/or painting. Records show that not all current staff have undertaken training in infection control. The home provides a small utility room where people can smoke if they wish. Examination of the accident book shows only one recorded accident, which was a minor accident. The fire safety officer has confirmed that fire safety in the home is satisfactory for the intended use. Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 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, 33, 34, Staff praise the manager and the company for the training offered and for the support they receive. Proper checks are made on job applicants - save one example where the person did not record all previous jobs on their application form. The companies’ policies and procedures are designed to support staff to carry out best practice standards. EVIDENCE: C.A.N. is a company that has a strong value base. Support staff confirm that they are encouraged to attend training courses and that these are provided by the company, including access to National Vocational Qualification training. Records show that the majority of staff have also undertaken training in disability awareness, administering medication, fire safety and first aid. All staff have received more than the minimum number of annual training days for 2005 required by the relevant standard. Training records confirm that the support staff are being supported to obtain a relevant National Vocational Qualification. Staff working in the home praise the manager and the company for the amount of training they can access. Records also show that all but one of the staff have had an appraisal of their performance since the home opened and that such appraisals give a proper consideration to the homes aims and objectives. There is evidence to confirm that all staff have undertaken a relevant Criminal Record/Protection of Vulnerable Adult check (Criminal Record Bureau/POVA). Systems are in place to ensure that there are proper recruitment checks, Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 Page 19 including completing an application form, the take up of references and verifying identify. However one person’s application did not detail all their previous jobs. This needs to be guarded against. The standard of care planning, risk assessment and review all show that this small staff are competent in these areas. Rotas confirm that there are sufficient staff on duty and that staff are deployed in a flexible way to ensure there are extra staff when needed. There is a well established staff team with the majority of staff having worked with the company for over 2 years. The staff team shows a good balance between age, experience, gender and ethnicity. Support staff confirm that staff meetings take place and that service users may attend them on occasions. Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 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): Residents’ rights and best interests are being adequately safeguarded. This appears to be a well managed service delivering its aims and objectives to an overall good standard. Some policies need updating. EVIDENCE: The company achieved the ‘Investor in People’ accreditation in March 2005. Service users praise the home and describe a service that supports their needs. They report feeling safe and they describe a caring, safe service. Support staff demonstrate an awareness of ensuring the well being and general health and safety of users. They show a good understanding of balancing opportunity with risk and of freedom with discipline. They manage these into the service design. For example policies underpin the main aims of the service. Policies detail that training is mandatory for all staff and outlines the system for induction, supervision and professional development. They promote team competency as well as individual competency. Assessment, including assessment of risk and care planning is well documented. There is, Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 Page 21 for such a small service, good attention to ensuring accountability, spotchecking and obtaining confirmation from service users what they think and noting it. Above all service users are active participants in their life planning and in key decisions that affect them. It is expected that service users will commit themselves to their agreed care pan and its objectives. The service has a competent and experienced manager who is deemed as a fit person by the Commission to manage this home. There is no evidence to indicate the home is not financial viable. Examination of the policy file shows that some policies are in need of further updating. While fire safety is taken seriously the current fire safety system is not ensuring that the fire alarm is tested every week. Three weeks in the previous 6 months it was not tested. It is noted that when a service user fails to respond to a fire alarm as at 27/9/05 there was no further evaluation as to the reasons why and what further actions including teaching and education about fire safety might prevent a further re-occurrence. Records also show that not all staff have practised a fire drill in this house. The guidance available to staff on infection control and restraint has been updated by a more recent versions and should be obtained. Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 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 3 2 4 3 3 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 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 4 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X X 3 3 X 2 3 3 X Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 Page 23 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. 1 2 Standard YA27 YA24 Regulation 21(2)(p) 22(2)(f) Requirement Remedial action must be taken to eliminate any cold spots in the house. The company must supply the Commission with an action plan that confirms when the refurbishment and redecoration of the house, including the kitchen and cleaning of gloss paintwork will be completed. Where service users do not respond appropriately to a fire alarm a risk assessment should be carried out and include what corrective actions can be taken to eliminate any identified risk Fire alarms must be tested in accordance the guidance from the local fire safety officer The manager should ensure all current staff have practised a fire drill Timescale for action 16/09/06 16/06/06 3 YA42 23(4)(e) 16/05/06 4 5 YA42 YA41 23(4)(c) 23(4) 16/05/06 16/05/06 Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 Page 24 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 YA24 YA41 Good Practice Recommendations It is recommended that all bedrooms be fitted with a wash hand basin. It is recommended that the company obtain recently published guidance on infection control and physical interventions and incorporate these policies into guidance for the staff. Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Drove Road (85) DS0000063428.V278101.R01.S.doc Version 5.1 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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