Inspection on 16/01/07 for 94 Saunders Close

This inspection was carried out on 16th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

94 Saunders Close 08/11/05

94 Saunders Close 07/06/05

94 Saunders Close 15/03/05

94 Saunders Close 06/04/04

Similar services:

Hunter`s Lodge

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

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

CARE HOME ADULTS 18-65 Saunders Close, 94 94 Saunders Close Kettering Northants NN16 0AP Lead Inspector Linda Clarke Unannounced Inspection 16th January 2007 09:00 Saunders Close, 94 DS0000032518.V324057.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 Saunders Close, 94 DS0000032518.V324057.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. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Saunders Close, 94 Address 94 Saunders Close Kettering Northants NN16 0AP 01536 410340 01536 481089 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.northamptonshire.gov.uk Northamptonshire County Council Mr Alan Victor Kemish Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The home is registered to accommodate 9 people in the category Learning Disability (LD) (18-65 years) for a maximum period of 6 months. No person falling within the category Learning Disability (LD) can be admitted where there are already 9 persons of category LD already in the home. Total number of service users in the home must not exceed 9. A maximum of 4 people who have a learning disability and a physical disability may be accommodated on the ground floor. One person whose predominant need is LD but who is over the age of 65 years may be accommodated. 8th November 2005 Date of last inspection Brief Description of the Service: 94 Saunders Close is a care home providing a respite service (short stay) offering personal care and accommodation for up to 9 persons with a learning disability and/or associated physical disability. The nine bedrooms are single and without en-suite facilities, four bedrooms are located on the ground floor and are all accessible to people who use a wheelchair, the ground floor provides specialist bathing and toilet facilities, and a kitchen which has been adapted to be accessible for service users with a wheelchair. The first floor provides three bedrooms and bathing and toileting facilities. Communal facilities including lounge and dining areas are located on the ground floor, and provide access to the garden and patio. A self contained ‘flat’ which provides lounge/dining space, a kitchenette, bathroom and two further bedrooms is located on the first floor. Information is located on site detailing the range of services offered, which includes the Statement of Purpose and a copy of the Commission for Social Care Inspections, Inspection Reports, which are located in the office. Fees payable are dependent upon an assessment undertaken by Care Management, which will determine the level of contribution payable by the service user. There are additional costs payable for activities and purchasing of personal items. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 5 Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process consisted of pre-planning the inspection, which included viewing the previous Inspection Report, reviewing of the pre-inspection questionnaire, and Comment Cards sent to service users by the Commission for Social Care Inspection, six service user Comment Cards were returned. The unannounced site visit commenced on the 16th January 2007 and lasted 1 day. The focus of the inspection is based upon the outcomes for the service users. The method of inspection was ‘case tracking’. This involved identifying service users with varying levels of care needs and looking at how these are being met by the staff at Saunders Close. Four service users were selected and discussions were held with two of them and three service users who were not part of the ‘case tracking’ process. The method of case tracking included the review of service users’ individual care records, discussions with staff of various delegated responsibilities within the home and reviewing the records, training records and the minutes of service user and team meetings. Of the Comment Cards returned by service users comments received were generally complimentary about the care. (Majority of service users were supported by care staff to complete the comment cards). • Quite happy with service provided. Can you do what you want? • • Depends on the weather at this time of year, and if the staff are short staffed or poorly. I like coming here but I also like to go home. What the service does well: Service users are encouraged to make decisions about their day-to-day lives, which are supported by risk assessments promoting their choice and safety. Service users benefit from accessing a range of activities and recreational pursuits within the local community Saunders Close provides a homely and comfortable environment, with the ground floor providing suitable equipment and access to service users with a physical disability who may use a wheelchair. The accommodation provides opportunities for individuals to gain independent living skills, by using the ‘training flat’. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 7 Service users are consulted during their stay as to the service they receive, through team meetings and one to one discussions. Meetings are used to ensure that service users are aware of specific safety measures such as the fire procedure. Staff employed are well trained and are able to meet the needs of service users, staff are aware of individual needs, and conversations with staff What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 8 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 Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 9 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, 4 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individuals considering accessing the service do not benefit from documentation detailing the services offered, in a format, which can easily be understood. The admission process it well managed, giving prospective service users the opportunity to visit and ‘test drive’ the home to ensure that care needs can be met. EVIDENCE: 94 Saunders Close has a Statement of Purpose which details the range of service it offers which includes information as to whom the service is aimed at, its aims and objectives, the environment, activities and details as to how referrals are made to the Home and information on staffing including numbers of and their training. The Statement of Purpose is a very detailed and complex document to read and digest, and is not written in plain English and is not in a format appropriate for individuals accessing Saunders Close. Service users accessing Saunders Close would benefit from a Service User Guide which contains information as to the services offered which is presented in a format appropriate for those to whom the service is aimed, for example through the use of plain English, signs, symbols and photographs. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 10 Service users who wish to access Saunders Close for a short break are assessed through the Care Management Team of Northamptonshire County Council who identifies their individual needs and their eligibility to receive services. When the level of need and eligibility has been determined the service user and their relatives/carers are visited by a member of staff of Saunders Close, who through discussion gathers more detailed information as to the individuals needs. Prospective service users and their relatives/carers are encouraged to visit the Home, spending time including overnight stays to ensure that the Home is suitable for their needs and meets their expectations. Prior to planned stays the ‘keyworker’ (a member of staff that takes the lead in liaising with family and reviewing care plans and attending meetings) of a service user contacts the service user and their family/carer by telephone, to establish as to whether there are any issues which staff need to be aware of, a form is completed which provides an over view of general needs and specific goals for the stay. The four files viewed did not contain a written contract detailing the terms and conditions of the service users stay at Saunders Close, the Registered Manager advised that this practice had ceased recently but a reason for this could not be identified. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 11 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, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users independence is promoted and are supported to make individual decisions in all aspects of their life that have a direct impact on the quality of care and choice of daily lifestyle. EVIDENCE: The care plans and records of four Service User were viewed, of which three were currently accessing a short break, two being on emergency placements. Care plans outlined the individual service user needs with regards to personal care and support, health care and daily routines and activities. This enables staff to provide a holistic approach to care. The format of care plans are not service user friendly, however are signed by service users and their carer/relatives. Service users would benefit from a format of care plan, which is easily understood, supported by pictures and symbols, and written in plain English. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 12 The Registered Manager is in the process of introducing a new format of care plan, which will provide greater details as to service users needs, goals and aspirations. It was discussed that the proposed care plan was a detailed document and would not be easily understood by service users. The Registered Manager advised that the care plan will then lead onto the development of person centred plans, which will be in a service user friendly format. Risk assessments are in place where an activity, event or the environment may present a risk to a service user, the assessment enables staff to support the individual to participate in daily living whilst not restricting their independence or choices. The daily records of the four service users were viewed, written information confirmed service users day to day decisions, for example what they wished to eat, when they wanted to go to bed and the choices of activity which they wished to participate in if any. Service users have the opportunity to take part in weekly meetings, minutes of meetings are taken, which details who took part and the issues discussed along with a record of any action, which need to take place. As a matter of routine the fire procedure is discussed and includes a fire drill. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 13 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, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy, experience and participate in different activities of interests and are supported to maintain their preferred individual daily routines and choice of lifestyle with the support of the staff, if required. EVIDENCE: The care plans of service users include information as to their daytime occupations, which vary for each service user and include attendance at various day centres, colleges and places of employment and detail transport arrangements. During the course of the site visit, service users returned from various placements whilst some individuals visited their friends from the day centre, which is on the same site. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 14 A programme of weekly activities is in place offering choices for internal and external events, consideration has been given as to the level of mobility and verbal communication required, this enables staff to support service users in engaging in activities which are most appropriate for their ability. Activities include board games, cookery, arts and craft, swimming, meals out and shopping to name some. All bedroom doors are lockable and service users have the option of keeping a key for their room for the duration of their stay, during the site inspection it was noted that some service users did lock their bedroom doors and that their privacy was respected, in that staff did not enter the bedroom in the service users absence in order to clean for example. Service users were observed eating their evening meal, which was relaxed and unhurried, service users are offered choices their care plan records as to the level of support if any is required by the service user and their likes and dislikes regarding meals. Service users who are able to make their own drinks are encouraged to do so in one of the kitchenettes, which are for the use of service users. One service user spoke to the Inspector about his working day, saying he gets up early to walk to work, he has worked at the same place for along time and enjoys it. One service user sat watching ‘James Bond, 007’ videos. Upon service users return from day care, college and work staff asked after service users day, and spend time sharing information, laughing and asking what they would like to eat for tea. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 15 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user health care needs and independence is promoted by receiving timely care and support provided in the preferred way. EVIDENCE: Care plans highlight the way in which service users require support, and include their preferences for times for getting up and going to bed. Saunders Close provides specialist equipment, which enables staff to support service users with their personal care in a sensitive and appropriate manner. During the course of the site visit a member of staff contacted a Community Nurse to make a referral in order that a service user on an emergency placement would have a health care assessment. Due to the nature of Saunders Close offering short term care the level of involvement with health care professionals is not intensive however care plans and records confirm that health care provision is made where a service user becomes unwell or where there is an ongoing health need such as epilepsy. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 16 Service users medication is managed by two members of staff at all times, this commences with recording the quantity of medication received into the home, the name of the medication including the frequency of administration is written onto a medication record, and throughout the week administered and signed by two members of staff. The medication and records for two service users were viewed and were found to be in good order. Staff undertake a two day training course on the medication, which is facilitated by ‘Boots’ pharmacists. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 17 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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by a robust and accessible complaints procedure and by staff trained in safe guarding adult processes. EVIDENCE: Saunders Close uses a form to record, complaints, concerns and ideas. This record is used by staff to alert outside agencies and service user families of their observations, but is also used to record information coming into Saunders Close. It was noted that complaints had been recorded and that the record went onto detail the outcome and any subsequent action, which would be taken. A compliment received from a parent was read, which stated ‘On behalf of (parents names) I would like to thank you and all your helpers for the excellent way that you look after (service users name).’ Three members of staff were spoken with, all were aware of the policies and procedures which they should follow should they have any concerns as to a service users welfare. Members of staff as part of their induction are given a copy of the General Social Care Council (GSCC) codes of practice, which outline their responsibilities with regards to care practice issues. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 18 Service users bring into Saunders Close with them money to spend on activities and personal items during their stay, service users who wish to take responsibility for their own expenditure during their stay are provided with a lockable facility within their bedroom in addition to a key to the rooms itself. For those service users who do not wish too, or who are unable to maintain control of their finances, have the option of asking staff to take responsibility for it, in these circumstances a record as to the amount received is recorded, along with expenditures incurred during the stay, monies not spent are handed to the service user to take home. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 19 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, 39 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with a warm, safe, clean, comfortable and wellmaintained environment suitable for their needs. EVIDENCE: Saunders Close has a hallway from which office and communal areas lead off. Service users benefit from a large open plan living and dining area, with the living area overlooking the garden, and provide access from the living area into the garden. Leading off from the living area is a kitchenette which is accessible to service users. Entrance and exit doors into the property and from the living area into the garden are accessible to service users who use a wheelchair, and can be operated independently from both the in and outside. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 20 The corridor on the ground floor leads to further ground floor lounge provision, bedroom, bathing and toileting facilities, all of which are accessible for service users requiring a wheelchair, with bathing and shower facilities being suitable for individuals with a physical disability by providing specialist equipment. Ground floor bedrooms have been designed in order that service users can access the wash hand basin and open windows from their wheelchair. The ground floor benefits from a full sized kitchen, which has been designed around service users with a physical disability and who use a wheelchair. The first floor, which is accessible by a stairwell, provides additional bedrooms, bathing and toilet facilities and a lounge. In addition the first floor has a ‘training flat’, with a small open plan kitchen, dining and living space, which is used to assess individuals abilities. Communal areas, bedroom and bathing facilities are decorated and furnished and create a comfortable and homely environment. Service uses are offered a key to their bedroom, with all bedrooms in addition providing a lockable facility for keeping personal items. The ground floor has a laundry facility. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 21 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): 31, 32, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of trained staff are recruited through a robust recruitment process ensuring that service user care and social needs are individually, collectively and safely met. EVIDENCE: The number of staff on duty at any one time is between four to five dependent upon the number of service users staying at the Home, and their needs. Residential Support Workers and Assistants support the Registered Manager, with further assistance from ancillary staff, which include cooks, and domestic staff. Staff as part of their recruitment and induction process are given a copy of the General Social Care Council Standards of Conduct and a job description outlining their roles and responsibilities within Saunders Close and Northamptonshire County Council. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 22 The Pre-Inspection Questionnaire submitted by the Registered Manager prior to the site visit declared that there are fifteen members of care staff employed of which twelve have attained a National Vocational Qualification in Care, which represents 80 of the staff group. The recruitment and selection procedure in place is robust and is supported by a Human Resource Team in accordance with the local authority equal opportunity policy and guidance. The files of two care staff were examined, which included a member of staff recently recruited. All files contained thorough pre-employment checks including the obtaining of a Criminal Record Bureau disclosure and/or protection of vulnerable adult check, a completed application form and two written references. Staff files identified the range of training, which staff receive and includes, NVQ, moving and handling, medication administration, infection control, first aid, autism, SCIP (Strategies for Crisis Intervention and Prevention) disability and equality, epilepsy and legislation. All members of staff have a record of the training they have attended. Three members of staff spoken with confirmed that they receive regular one to one supervisions, which an opportunity to review issues affecting service users, day-to-day care practices and training. Service users benefit from an effective team of staff who meet on a regular basis, this ensures that staff have up to date information. Records showed that staff meetings are held on a weekly basis, for the team as a whole, and for Residential Support Workers and Assistants, during the site visit a team meeting was held, which provided an opportunity for the Registered Manager and staff to discuss the management of provision with regards to short term care, the planning and booking of short term provision, discussing issues affecting service users and points relevant to the day to day management. The minutes are in place for all staff meetings, detailing the issues discussed and any action requires to be taken and by whom. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager offers a clear sense of leadership, ensuring service user health; safety and welfare are promoted. Service users are provided with opportunities to comment on and affect the service they receive. EVIDENCE: The Registered Manager, Mr Alan Kemish has for thirteen years worked within a managerial capacity, managing short stay services for adults with a learning disability. Mr. Kemish has attained and attended various courses, which includes gaining Technology Education Council Higher National Certificate in Management and Social Care, and a Diploma of Higher Education in Social Work. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 24 Northamptonshire County Council (NCC) has a monthly monitoring report, which is in part the responsibility of the Registered Manager to complete. A member of the NCC Quality Team, will visit the home unannounced, visits will incorporate weekends and evenings to undertake an audit of the service being provided, which will include speaking with services and visitors, viewing records, speaking with staff on duty, viewing the environment and following upon issues identified at the previous visit. The two most recent reports were viewed, which demonstrated that issues identified by the Quality Team are acted upon by the Registered Manager, which ensures that the service, service users receive is fit for purpose. Service users are encouraged to complete a questionnaire at the end of their short stay; in some instances this requires the support of a member of staff. It is suggested that in order for service users to comment without influence that a person other than a staff member should provide support in completing the document. The Registered Manager suggested that they might be able to consider using day centre care staff. Service users are also able to raise issues at weekly meetings, whereby minutes are taken and any action required is noted. Service users and their relatives/carers could influence the service with greater effect if they were to take part in a formal quality review process, it was suggested to the Registered Manager this could take place one or twice a year, and could include questionnaires being sent to parents/carers and service users. An audit of responses to be published and copied to relatives/carers and service users including an action plan of any issues raised. The Pre Inspection Questionnaire submitted prior to the CSCI prior to the site visit detailed the regular maintenance of health and safety systems within the home, including fire systems and equipment, environmental health visits, central heating systems and emergency call systems. Records detailing fire drills and checks were viewed, and found tests to be carried out on a regular basis. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 25 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 1 2 3 3 X 4 3 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 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 3 3 3 X 3 3 3 3 3 3 3 Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 26 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 Requirement The Registered Person to produce a Service Users Guide, which reflects the current situation, and is produced in a format appropriate to the service user group to which it provides a service. The Registered Person to ensure that service users accessing Saunders Close receive a copy of the agreement specifying the arrangements of their stay. Timescale for action 31/03/07 2 YA5 5(3) 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations It is recommended that service users are provided with a care plan which encompasses all their needs, including their goals and aspirations in a format which they understand and can be actively involved. It is recommended that the views of service users, carers/relatives are sought, with a report and action plan DS0000032518.V324057.R01.S.doc Version 5.2 Page 27 2 YA39 Saunders Close, 94 being produced and distributed to the participants and those who access services at Saunders Close. Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Saunders Close, 94 DS0000032518.V324057.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!