Inspection on 20/06/07 for Andlaw House

This inspection was carried out on 20th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Andlaw House 07/07/09

Andlaw House 10/11/05

Andlaw House 26/01/05

Andlaw House 02/08/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Andlaw House 126 Bartholomew Street West Exeter Devon EX4 3AJ Lead Inspector Louise Delacroix Unannounced Inspection 20th June 2007 10:05 Andlaw House DS0000021875.V336554.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 Andlaw House DS0000021875.V336554.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. Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Andlaw House Address 126 Bartholomew Street West Exeter Devon EX4 3AJ 01392 490366 01392 490399 darrenwickens@sense.org.uk www.sense.org.uk Sense, The National Deafblind and Rubella Association Darren Wickens Care Home 10 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) Category(ies) of Learning disability (10), Physical disability (6), registration, with number Sensory impairment (10) of places Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age Range: 18 to 50 years Date of last inspection 10th November 2005 Brief Description of the Service: Andlaw House is a two-storey purpose built home, close to the centre of Exeter. It is divided into two flats with separate staff teams. However it is registered as one home. There are also garden areas that are accessible to people living at the home. The annual fee is between £62,000 - £90,000. There are no additional charges. Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and lasted six and half hours. Ten people were living at the home. We were not able to gain the views of people living at the home because of their complex communication needs. Instead, time was spent observing the care practice of staff in communal areas of the home, and the way they interacted with the people using these rooms so we could gain an impression of what it what like to live at the home. Time was also spent talking with members of staff and the manager. Medication records, financial records, staff recruitment and training files, and plans of care were also looked at. The Commission for Social Care Inspection (CSCI) asked for the home to send out a range of surveys published by the Commission to gain feedback from people in contact with the service. Six relatives/visitors and seven health and social care professionals responded. Surveys were also sent to the staff team and four returned them. All responses have been included in the report, as have details from the home’s pre-inspection report, which gives details about the service and is completed by the manager. What the service does well: The home provides a thorough and comprehensive assessment process and people are encouraged to visit. Each person living at the home has a comprehensive plan of care, which recognises his or her individuality. The staff group are skilled in enabling people to make decisions and supporting them to maintain an independent lifestyle, which involves informed risk taking. There are strong links with the local community and people are supported to access social opportunities that enhance their own development and maintain interests. The service recognises the need for people to have contact with those that are important to them, and to be able to influence their daily routines. The home provides a varied diet in a flexible manner. People receive personal support in the way they prefer and require. There is a strong emphasis on meeting both the physical and emotional needs of people living at the home with excellent contacts with health services. Medication is well managed. Staff are trained in both mandatory and specialist areas of care. They are skilled in their approach, and well supported with positive role models and regular observation and supervision of their work. There is a focus on making the environment more accessible to the people living at the home, including those with complex disabilities with safety checks in place. The home has shown a commitment to gaining feedback about the Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 6 quality of the service and people know how to make a complaint and feel listened to. 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. Andlaw House DS0000021875.V336554.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 Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2 and 4 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments, which include visits to the service, are carried out to a high standard. They are comprehensive and reflect the individuality of each person. EVIDENCE: The service carries out full assessments, including advice from specialists, and then works with the person and their representatives before they move to the home to gain an understanding of their social, emotional and physical needs. Assessments from social care professionals, i.e. care managers also play an important role within the assessment. One care manager commented that the service provides a good ‘set up’ process for assessing and admitting new service users. Another care manager also commented that the service provided ‘excellent’ assessments. Since the last CSCI inspection, one new person has moved into the home. They were able to visit the home and take part in a trial stay to help ensure that the service met their needs. There was recognition of their age and the need for a considered transition into adult services. In their survey response four staff members said they were not asked to care for people outside their area of experience, which shows that the assessment process works well, with Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 9 the service ensuring they can meet the needs of new people moving to the home. Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 and 9 were inspected. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care needs are met to a high standard in an individual manner by caring and informed staff. The ethos of the home promotes the rights of people living there to make choices in their lives. People are supported to take risks to enhance their independence. EVIDENCE: Plans of care are generated from detailed assessments and have a holistic approach to the lives of the people living at the home. They are well worded and sensitively portray how support should be provided in a way that recognises the person’s strengths and areas for development. This was further confirmed by discussions with staff, who were clear that their role was to maximise the potential of people using the service. Plans of care contain a range of information, including acknowledging the people who are important to the person living at the home. A parent said in Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 11 their survey ‘I am more than pleased with Andlaw House. They never forget family birthdays, my son is so very happy’. There are also ‘pen pictures’ of the person that reflects their individuality and guidelines on supporting people with their behaviour. Daily records are well written, and appropriately and descriptively worded. Reviews are in place and happen once a year and generally involve significant people in the person’s life, although one care manager said they were not always informed of reviews and changes. Another care manager said that the quality of review information is excellent and is provided in a service user-friendly format, where possible. The manager of the service spoke about the work that has been carried out to increase the accessibility in the presentation of information e.g. PowerPoint style. Through conversation and observation, it was apparent that staff were following the guidelines stated in the care plans showing they were working documents. Staff spoke about how they work towards enabling people to make decisions. For example, being aware that all senses can be used to communicate choice, such as smell when choosing food. During the inspection, a staff member was observed using objects to signify different activities so that the person they were working with could be involved in the decision-making. A service user had a bag that belonged to them with objects that they liked. They were observed choosing what they took out with them for the day. Staff gave examples of how they tried to provide choice for people living at the home, which recognised their complex communication needs. This is based on their own knowledge of working alongside the service user, the positive role models from other staff, and the quality of the plans of care, such as the ‘pen pictures’, which have a real sense of trying to convey individuality. Staff were observed focussing on people’s body language, facial expressions and vocalisation to try and find out their wishes. A parent said that supporting service users to live as they choose was always the ‘key ambition of staff’ while another comment was that the staff ‘try very hard to make our son’s life as fulfilling as possible and he has never been happier’. Risk assessments are in place and reviewed. Staff spoke about the importance of reading the mood and body language of service users, as well as communicating with them in their preferred language to help measure risk. A member of staff was heard arranging a back up plan if the person they were supporting became unwell whilst out in Exeter. This was based on observation, and knowledge of the person’s medical history and how this had affected them the night before. People are supported to be involved in activities that they enjoy such as riding, swimming and adventure holidays. A parent said ‘The carers are very sensitive to the needs of our daughter and will follow her needs on any particular day i.e. if she is well she enjoys being out and about, if she feels unwell but needing company they will read and spend time with her’. Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15,16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There are strong links with the local community, which support and enrich people’s social opportunities and personal development. People are supported to maintain relationships important to them. Meals are varied and meet the individual needs of people living at the home. EVIDENCE: Discussions with staff and detailed plans of care show that people living at the home have access to local community resources. The staff group have worked hard to ensure that despite people’s complex needs they have access to the same level of activities as their peer groups e.g. art classes, horse riding, swimming and access to a Jacuzzi. Recognition was shown in care records of how to ensure people whose behaviour is complex can be supported to be included in these events. Up to date records are kept of each person’s day, which detail their integration into community life by making use of the local Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 13 services. Sometimes people will go out in a small group if they have a shared interest but there were also plenty of examples of one to one activities. The service also arranges holidays and a staff member spoke enthusiastically about the very positive reaction of a service user to a wide range of adventure activities run by the Calvert Trust. Care managers commented in their surveys that the service has ‘provided a good range of person centred activities’ and another person responded to the question does the home support individuals to live as they choose ‘very much so’. Another person said that the service provided an individual programme of care for their client. For example, during the inspection, one person had one to one care and made a cake with support from their carer. Staff recognised the importance of enabling service users to maintain their relationships with friends and family. There are no restrictions on visiting times, which was confirmed by a relative, and family members said in their survey responses that there was ‘excellent key worker contact’ and that the service ‘fully involves parents and family members’. Another family said the contact was usually instigated by them but was welcomed by staff. One person commented that the home supported them when their relative stayed with them and ‘most of all keep my son happy’. A care manager confirmed that the service communicates well with families saying ‘I have been very impressed with the care that has been given to my patient and also the family support’. One family commented that they were not always told of episodes of ill health or incidents at the home. Another relative said that information was provided on a ‘need to know basis’. Staff spoke about the balance between privacy of people living at the home and keeping families involved. A health and social care professional commented that ‘ the service responds to the needs of my service user in all areas, including their disability and sexuality’. The manager spoke about the specialist guidance given to support one service user and their sexuality. Information was seen to show the home’s contact with the specialist. This contact was also confirmed by a comment in a survey from a health and social care professional when they said that the service ‘ gives confidence in having trained and experienced staff and is able to access specialist support and assessment within Sense’s wider organisation’. During the inspection, time was spent observing the daily routine of some of the people living in the home. These were different depending on the individual, for example one person was in bed after being unwell, one person was having their breakfast and other people were up and ready to go swimming. Daily records showed a variety of routines. The manner of staff was respectful when they spoke about the people living at the home, and where possible they included them in conversations and responded to service users’ vocalisations. This was observed during a tour of the building when we met people living at the home. Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 14 Staff spoke about the food likes and dislikes of the people living at the home and how these were catered for. These were also listed in individual plans of care. Meals were seen happening at the individual’s pace and in a relaxed atmosphere. People at the home eat at different times depending on their plans for the day. Andlaw House DS0000021875.V336554.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): Standards 18,19 and 20 were inspected. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service provides a high standard of support and care, which reflects the individual needs of the people living at the home, and promotes good access to health care services. People are protected by good medication practice, and there is recognition in assessments and guidance for staff to work towards meeting both the physical and emotional needs of the people living at the home. EVIDENCE: Clear instructions are given in plans of care about the level of support that people require for personal care. Daily records within plans of care showed flexible times for going to bed and getting up. Discussion and observation of staff showed a consistent approach to recognising the individual needs of people living at the home. A health and social professional said that the service had ‘ a total understanding of the needs of my client’. The home has excellent contact with health services as shown through care plans and discussions with staff. There is a strong commitment by the service to meet the changing health needs of service users and working closely with Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 16 health services i.e. the hospital to ensure that they have all the necessary information. This was observed on the day of inspection. Staff support service users during hospital admissions to provide continuity of care and reassurance, as well as in one case acting as an advocate and challenging poor practice. It was clear on the day of inspection that service user’s needs are central and staff were seen offering to work extra shifts to respond to a change of plan by the hospital. A health and social care professional said the service ‘is flexible and caring in the way that staff implement care’. All the care managers said in their survey responses that individuals’ health care needs are always well met. A GP who has contact with the service said that the care service always seeks advice and acts upon it to manage and improve individuals’ health care needs. Families acknowledged how their relatives have benefited from having their physical, emotional and social needs met. The home reports incidents relating to serious health problems to CSCI, and records show that appropriate action has been taken. The GP said that the service always managed medication well. A minor improvement has meant that medication recording can be better audited. Staff monitored pain relief during the inspection, and were quick to pick up on people’s changes of mood and well-being. A staff member spoke about their medication training and how this was updated. Medication records are well maintained, and the staff member spoke about their administration technique, which indicated that they administered medication in an appropriate manner with safety mechanisms built into the process to help ensure that mistakes are not made. Staff talked knowledgeably about the different medical needs of people living in the home, how medication reviews took place and seeking advice from GPs. Plans of care showed that protocols were in place for the use of specialist procedures, and staff explained these and what guidelines were in place if a person chose to refuse medication. Andlaw House DS0000021875.V336554.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): Standards 22 and 23 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are protected by the complaints and safe guarding procedures. EVIDENCE: All care managers and relatives said in their survey responses that the home responded appropriately if concerns were raised. One person commented that the service had a ‘very co-operative approach’. All the relatives who responded said that they knew how to make a complaint. There has been one complaint made to the service prior to the appointment of the current manager. CSCI were informed of this complaint and the action taken. The service informs CSCI of incidents in the home and the action taken to address these. Staff who responded to the CSCI survey said that they were aware of their role in safeguarding people living at the home. During the inspection, teams contained strong and positive role models within them, providing clear direction and examples of good practice for less experienced staff. Incidents are audited to look for patterns and triggers, and the manager explained that the service has access to specialist advice on challenging behaviour so that an action plan can be drawn up. Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25 and 30 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally well decorated, whilst bedrooms recognise the individual tastes and interests of people using them. EVIDENCE: The home has been decorated to provide colour contrasts to act as an aid for people with a visual impairment. There is now a system to monitor the temperature of one of the bedrooms with an action plan in place. Furnishings and fixtures are generally domestic in style, and new communal furniture has been bought for one lounge, while the manager explained furniture for the second lounge is on order. A staff member explained how routinely paintwork was freshened up. However, two of the communal bathrooms were tired in appearance, one of the baths had a broken board on the front, and a shower seat and grouting around tiles were marked. Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 19 Rooms belonging to people living at the home showed their individual tastes and had been thoughtfully decorated to suit their differing responses to colours, light, movement and noise. On the day of the inspection, the home was clean and odour free. Staff were clear about the infection control measures in the home and the precautions taken, and spoke about their training in this area. Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards inspected were 32,33,35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a committed staff team, with a range of experience, whose training opportunities and skills benefit the people living at the home. However, minor changes to recruitment and training records will provide a safer system. EVIDENCE: The staff group observed during the inspection contained strong and positive role models within them, providing clear direction and examples of good practice. Staff were caring, informative and sensitive to the individual needs of people. There appeared to be a good rapport between staff with good quality information shared, which was reflected in surveys when staff members commented that staff groups supported each other. Teams are made up of male and female staff to reflect the client group, and staff were clear about the boundaries relating to this. There were appropriate levels of staff on duty, which staff confirmed. The service does use bank or agency staff on occasions but the manager said they always aimed for the same workers to achieve experience and consistency. Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 21 There were a number of positive comments about the skills of the staff group from both families/visitors and social and health care professionals. The service has achieved a high level of NVQ qualified staff. Families/visitors comments included a ‘great ‘caring’ team’, ‘they are very dedicated to their clients and look after them with great care and patience’, and they ‘show huge respect and understanding of the people they care for’. A health and social care professional wrote in their survey ‘this is one of the few services which, upon leaving my annual visit, I feel humbled by the devotion of the staff to the care of my client. I hold them up as an example/aspiration of excellence in the care of a profoundly disabled fellow human being’. Another said that the staff team ‘appear to constantly strive to improve/create a person centred service where possible’. Three recruitment files were looked at for members of staff who have been recruited since the last inspection. All three files showed that Police checks were in place before staff started working with people living at the home, and there were appropriate levels of identification on file. All three files contained two written references each but one file did not have a full employment history with dates of employment, and one reference had been sent to a referee’s home address, not the business address. There was also a discrepancy in information that had been provided, which had not been followed up. During the inspection, staff spoke positively about the training provided and explained how this was updated. Staff surveys also showed that funding and time was available for training. Documentation detailing the home’s training schedule showed a broad range of both mandatory courses and specialist courses, such as communication and values. However, training information provided with the pre-inspection questionnaire showed gaps in training or overdue refresher courses. Records for fire training were also unclear as to when people’s knowledge has been updated. Staff said in their surveys that they felt well supported with their work through regular meetings with the manager, one to one supervision, observation of their work and through group meetings. Care staff said that they were clear about the policies of the organisations and their subsequent responsibilities. They said they knew what to do in an emergency and felt they received enough support to do the job well. A member of staff commented ‘a good happy working environment leads to happy staff/happy individuals’. Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This service has good processes to ensure that the quality and safety of the service is monitored to benefit people living at the home. EVIDENCE: The home did not have a registered manager at the time of inspection. However, since this time it has been confirmed by CSCI’s Central Registration Team that the acting manager will be registered with CSCI. The manager spoke about how the service produces its own quality assurance surveys, which are sent out annually. There is also an annual family weekend, which provides time to meet with people in contact with the home, and is used for example to discuss issues relating to the people using the service. There is also a family liaison officer in post. Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 23 The home’s pre-inspection questionnaire states that safety checks are up to date and the manager could show that safety inspections were booked e.g. for hoists. There have been recent inspections by both the fire services and environmental health services, and the manager said that subsequent recommendations have been followed up. Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 3 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 3 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 4 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 4 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x x x 3 x x 3 x Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA34 Regulation 19 1 (b) Requirement Application forms for staff must detail a full employment history with any discrepancies or gaps discussed and the outcome recorded. Timescale for action 31/07/07 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. 2. 3. Refer to Standard YA24 YA34 YA35 Good Practice Recommendations Repairs, decoration and cleanliness of equipment should be reviewed, and where necessary, addressed in communal bathrooms. References should be sent to the business address not the referee’s home address. Training for all staff should be audited to ensure that refresher training is up to date and logged, with updates arranged where necessary. Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP Tel: 01364 651800 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 Andlaw House DS0000021875.V336554.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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