Inspection on 27/05/08 for Ashwood Avenue

This inspection was carried out on 27th May 2008.

CSCI found this care home to be providing an Good service.

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

Ashwood Avenue 11/04/07

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Ashwood Avenue 36 - 38 Ashwood Avenue Kirkby in Ashfield Nottingham Nottinghamshire NG17 7QA Lead Inspector Claire Williams Unannounced Inspection 27th May 2008 10:30 Ashwood Avenue DS0000068816.V365547.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 Ashwood Avenue DS0000068816.V365547.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. Ashwood Avenue DS0000068816.V365547.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashwood Avenue Address 36 - 38 Ashwood Avenue Kirkby in Ashfield Nottingham Nottinghamshire NG17 7QA 01623 754527 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.mencap.org.uk Royal Mencap Society Bridget Jordan Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Ashwood Avenue DS0000068816.V365547.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Royal Mencap Society is registered to provide accommodation and personal care at Ashwood Avenue, 36 - 38 Ashwood Avenue, Kirkby in Ashfield, Nottingham, NG17 7QA for a maximum of 12 people whose primary care needs fall within the following numbers and categories: Learning Disabilities (LD) - 12. 11th April 2007 Date of last inspection Brief Description of the Service: 36/38 Ashwood Avenue is a care home consisting of two purpose built bungalows providing care and support for up to twelve adults with a learning disability. The home was registered with Mencap on 1st November 2006. Nottinghamshire Community Housing Association owns the building. The home is located on the outskirts of Kirkby in Ashfield not too far from shops, pubs, the post office and other local amenities. All of the bedrooms are single; none are en-suite. Residents with mobility difficulties are assessed by an occupational therapist for any equipment they need to be able to live and be supported safely in the home. The home has a garden area, which is accessible and there is car parking available to the front of the bungalows. The fees for the home are from £330 to £374.00 per week topped up by individuals’ assessed income support. The fees do not include toiletries, and clothing. A copy of the Statement of purpose and report are available upon request and are located in the office. Ashwood Avenue DS0000068816.V365547.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for the service is two star. This means the people who use the service experience good quality outcomes The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views of the service provided. This process considers the service’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The inspection visit was unannounced and took place over a period of 1 day. In order to prepare for this visit we looked at all the information that we have received, or asked for, since the last key inspection on the 11th April 2007. This included: • The annual quality assurance assessment (AQAA). This is a selfassessment that focuses on how well outcomes are being met for people using the service. • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • The previous key inspection report. During the site visit case tracking was included as part of the methodology. This involved the sampling of a total of three people’s files representing a cross section of the care needs of individuals within the home. Discussions were held with those individuals as able, and observations were made of the interactions between the staff and the people who live in this service. Individuals care planning and associated care records were also examined and their private and communal facilities inspected. Discussions were also held with staff about the arrangements for their care and also for staffs’ recruitment, induction, deployment, training and supervision. What the service does well: People are confident that the service can support them, as comprehensive assessments are undertaken before people move into this service. People’s needs, and aspirations are recorded in support plans that are person centred and accessible to the individual. This ensures the staff team have access to information to ensure they support individuals based on their individual preferences. People are supported to take risks to enable them to stay independent, which is managed by the risk assessments in place. People have access to valued Ashwood Avenue DS0000068816.V365547.R01.S.doc Version 5.2 Page 6 activities and experiences in the community, which enables them to live fulfilling lives. People feel safe and confident to raise any concerns as they said the manager and staff are “helpful, supportive and easy to talk to”. People said they like where they live because “it is nice, clean and homely”. The staff team are trained motivated and committed to their role in supporting people. Staff members have access to positive training opportunities to enable them to have the skills and knowledge to fulfil their responsibilities. Quality assurance systems are in place to ensure the service is managed in the best interests of the people who live here. What has improved since the last inspection? What they could do better: The documentation in place would benefit from being reviewed to include the six strands of diversity, which are: race, gender identity, disability, sexual orientation, age, religion and belief. This will make it inclusive to all people. New guidance has been released about the storage of controlled medication in care homes. Therefore this service will need to obtain this guidance and take the required action to ensure they comply with the new regulations to ensure medication is stored safely. During discussion it was reported that people would benefit from having a sensory area. Ashwood Avenue DS0000068816.V365547.R01.S.doc Version 5.2 Page 7 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. Ashwood Avenue DS0000068816.V365547.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 Ashwood Avenue DS0000068816.V365547.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): National Minimum Standards 1, 2, 3, and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with sufficient information about the service in order for them, and their relatives, to make an informed decision about whether the service is right for them. EVIDENCE: In the self assessment they we received they said they provide people with accessible information about the service and choices available in person centred support plans. They encourage the involvement from individuals familes, carers and previous care providers to assist with the tranistional process. They said they have devised a new Statement of purpose. At this inspection the service demonstrated that they do provide people with the following information; an accessible combined statement of purpose and service user guide, a contract and a tenancy agreement. This means people have the required information in order to be aware of their rights and the facilities available. It was reported that as part of the transitional process people are encouraged and have previously undertaken trial visits to the home in order to make an informed decision about moving into this service. There have been no new admissions, but it was reported that the service have the required Ashwood Avenue DS0000068816.V365547.R01.S.doc Version 5.2 Page 10 documentation in place in order to undertake a full and comprehensive assessment of a persons needs and compatibility. This is to ensure the placement is right for them and for the people currently living in this home. There were no people accommodated at the time of the site visit with diverse cultural or religious needs. It would be beneficial however for all documentation to be reviewed considering the six areas of diversity, so that is it inclusive to all people. Ashwood Avenue DS0000068816.V365547.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): National Minimum Standards 6, 7, and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Person centred plans are in place which ensures peoples needs are met in accordance with their individual preferences. EVIDENCE: In the self-assessment that we received they said they encourage people’s involvement by faciltating house meetings. They said work is ongoing work to ensure individuals suport plans and risk assessemnts are person centred. They have devised a new staff rota to meet the needs of people so that they can access more activties. The files for three people were examined. The support plans covered a variety of areas, which were applicable to the needs of the individual. All support plans were person centred and detailed. There was evidence to support that people had agreed with their plan if they were able to. Support plans were in place, which identified the persons preferred communication style. This Ashwood Avenue DS0000068816.V365547.R01.S.doc Version 5.2 Page 12 ensures staff are aware of the method of communication that should be used in order to enable the person to lead a full life that promotes independence and choice. Each person has been allocated a key worker, and they are currently working in partnership in order to devise a life book, which will provide more information about the person from their perspective and through the use of pictures. People are supported to take risks to enable them to stay independent and staff have access to information on how to provide this support by reading the risk assessments in place in each persons file. People are asked about and are involved in aspects of life in the home through the provision of regular meetings and discussions that are held. Observations supported that people are encouraged to make choices and are consulted on all aspects of their life. One comment made by a person was: “I like living here and we have choices and the staff are good and kind”. It was reported that work would soon commence to develop support plans about individual’s capacity to make decisions about aspects of their life. This is in accordance with the requirements of the mental capacity act. Ashwood Avenue DS0000068816.V365547.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): National Minimum Standards 12, 13, 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. People who use this service are able to make choices about their life style and are supported to develop their life skills. People have access to recreational activities, which meet their individual preferences and expectations. EVIDENCE: In the self-assessment that we received they said all people have planned their summer holiday, and winter holiday so each person will have two holidays this year. People are supported to maintain contact with their friends and family by phone. They said people are actively encouraged to use local facilities such as the shops, pub, and have meals out. Individuals are supported to manage their bank accounts to promote their independence. People spoke about the activities they attend and the experiences they have. Individuals were preparing to go out for either a lunchtime or evening meal. Ashwood Avenue DS0000068816.V365547.R01.S.doc Version 5.2 Page 14 One person who went out at lunchtime said: “I had a lovely time the food was nice and I am very full now”. People told us about their plans for their summer and winter holidays and individuals commented on how excited they were. There was photos displayed around each house in various locations of past trips to London, the zoo, and various other locations. People said they have “busy lives” and their was evidence both in their support files and in the activities folder of all of the experiences and community facilities that they access. Some individuals attend a day centre and those that do not have a day placement have structured activities of their choice planned for each week. There was support plans in all three files examined, which detailed the person’s activities, hobbies and aspirations. Their was evidence in peoples files of the ongoing support provided to enable individuals to keep in touch with their family and friends. Observations supported that people’s dignity and rights are respected in their daily lives. A new pictorial, menu has been devised to enable people without verbal communication to choose their preferred meal. The menu for the week was displayed in the kitchen area and there were two choices available at each mealtime. People spoken to said they enjoyed the food provided. We had an evening meal with people who lived in one of the bungalows and observations supported that choices were offered, individual dietary needs were catered for and people were supported in a dignified and respectful way to eat their meal. Ashwood Avenue DS0000068816.V365547.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): National Minimum Standards 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. The heath and personal care that people receive is based on their individual needs, and delivered in accordance with the principles of respect, dignity and privacy. EVIDENCE: In the self assessment that we received they said all individuals are supported to all medical appointment’s and health professional review meetings. They said the chiropodist visits every eight weeks at the home, and that each person attends the well-man and well-woman clinic each year. All people have pen pictures on how they like their medication to be administered. Each file that we examined contained pictorial health action plans, which covered all of the person’s healthcare needs. It was clear from the records that each individual is supported to attend any medical appointments, including the well man/woman clinic as mentioned above. This ensures peoples healthcare needs are monitored. Ashwood Avenue DS0000068816.V365547.R01.S.doc Version 5.2 Page 16 Peoples said they receive personal support from staff in the way they prefer and want. Information is provided in each person’s plan concerning their routines and preferences enabling the staff team to provide appropriate support. Each person does have a pictorial medication support plan, which informs staff on how they like their medication to be administered. It also details what medication the person is prescribed and the reasons for this and any potential side effects, which is good practice. Examination of the medication records demonstrated that people receive their medication as prescribed. We did identified that the medication record had not been signed for one person and the reasons for this was investigated straight away and addressed by the deputy manager. Information was provided concerning the new guidance about the storage of controlled drugs as the service does not currently meet the new specifications. In response to a recommendation made in the last report a homely remedies policy has been devised, and all people have a support plan to indicate what homely remedies they are able to take. Ashwood Avenue DS0000068816.V365547.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): National Minimum Standards 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures for handling complaints and safeguarding were in place, ensuring that people are fully protected. EVIDENCE: In the self-assessment that we received they said that Mencap has a comprehensive compliments and complaints procedure. They have a file divised for what actions to take and procedures to follow in the event of complaints and guidelines in place for reporting incidents for staff to follow. Mencap have an adult protection policy that is clear and provides guidance about staff members responsibility to work within the local authority vulnerable adults procedures. They said staff have attended safeguarding adults training course. The complaints procedure was displayed in an accessible format for the people who live in this service. If people have concerns about their care they or people close to them know how to complain. One person said “the manager would deal with things straight away if I am unhappy about something”. The complaint records demonstrated that all complaints are responded to within an agreed timescale. The service has received one complaint since the last inspection and this has been dealt with. A copy of the local Multi-agency safeguarding procedures was in place along with internal policies and procedures in relation to abuse, whistle blowing, and Ashwood Avenue DS0000068816.V365547.R01.S.doc Version 5.2 Page 18 support mechanisms. The records seen demonstrated that all staff have had training in safeguarding. During discussions with the staff members they all demonstrated their knowledge on what actions to take in the event of witnessing a potential abusive situation. There have been two safeguarding adult referrals and investigations since the last inspection and the service followed the procedures and took the required action in response to these. People are supported to manage their own finances and each person had support plans in place for this. Systems were in place for the safekeeping of people’s finances and these was checked and found to be satisfactory. Ashwood Avenue DS0000068816.V365547.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): National Minimum Standards 24, 25, 26, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a homely and comfortable environment that was well furnished and maintained. EVIDENCE: In the self assessment that we received they said CC-TV cameras are in place to ensure the safety of all service users, staff, families, and friends that visit. New windows and patio doors have been fitted to both bungalows. Each bungalow has had a new kitchen and people chose their colour scheme. They said people have the choice and opportunity to decorate their rooms to their individual taste. As recorded above there have been significant improvements made to the environment to make it safe and homely for people to enjoy. The implementation of the cameras has reduced the instances of vandalism that the service previous had experienced. Both bungalows have been refurnished and had new fixtures and fittings. One person said “I like living here its safe now and looks nice after being redecorated”. Ashwood Avenue DS0000068816.V365547.R01.S.doc Version 5.2 Page 20 All work that had been previously identified in the last report has been addressed. Individuals invited us to view their bedrooms, which were personalised to their preferences. People can access a secure garden area, which has been developed since the last visit and which people said they now enjoy using and sitting in during the nice weather. Ashwood Avenue DS0000068816.V365547.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): National Minimum Standards 32, 34, and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by staff that are appropriately trained and recruited to ensure their needs are met and their well being safeguarded. EVIDENCE: In the self-assessment they said; Mencap has a clear induction process and ongoing training for all staff. All staff receive training relevant to the peoples needs, and all mandatory training is updated. Staff have regular supervision and annually performance appraisal. Staff have opportunities to voice their views through an open door policy and monthly staff meetings. The recruitment files for 3 of the most recently appointed staff members were examined. Each file contained all of the recruitment information that is required by the current regulations in order to protect people that live in this home. Each staff member had a training file, which contained certificates of the training undertaken. This demonstrated that staff had undertaken all of the required mandatory training and refresher training equipping them with the Ashwood Avenue DS0000068816.V365547.R01.S.doc Version 5.2 Page 22 skills and knowledge to meet people’s needs. Staff members spoken to said they access training applicable to the needs of the people they support and one staff member said “ we have positive training opportunities”. All new staff undertake an skills for care induction, specialising in working with people with learning disabilities. The discussions with staff members and the records demonstrated the commitment towards obtaining a national vocational qualification and many staff have already achieved a level 2 and are working towards a level 3. During discussions with staff members one staff member said they would like to attend training in makaton in order to use as a method of communication with people without verbal communication. All staff spoke to confirmed that they have regular supervision and team meetings and records in place supported this. People spoke positively about the staff team and the following comments were made: “they are good and help me when I need it” “the staff are nice and friendly and help me when I need them to”. Observations supported that the staff members had a good knowledge of peoples support needs and provided assistance in accordance with peoples preferences. Feedback confirmed that the staffing levels were in accordance with people needs. However it was reported that at times the staffing levels sometimes result in people not always being able to access community facilities, but the staff rotas have recently been reviewed to try and address this issue. It was also reported that due to the time staff finish duty this sometimes impacts on the length of time that people can access community facilities. The staff team in place reflects the gender and age mix of the people living in this home, therefore meetings people equality and diversity needs. Ashwood Avenue DS0000068816.V365547.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): National Minimum Standards 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 service is managed to ensure the health and safety of individuals is promoted and safeguarded. EVIDENCE: In the self-assessment they said they have good links with external agencies ensuring that peoples need are met. They ensure all incidents are reported to relevent departments and regulations 37 are sent to us to report any significant events. The area service manager vsits on the monthly basis and completes a report. They said staff have access to information and systems in order to assist them with their role. People spoken to said they thought the service was managed well and they found the manager to be “easy to talk to and approachable”. The service does keep us informed of any significant events and copies of the reports following Ashwood Avenue DS0000068816.V365547.R01.S.doc Version 5.2 Page 24 the monthly visits were seen. In addition to this quality assurance and health and safety audits are undertaken to make sure people live in a safe environment, which is meeting their needs. People have opportunities to talk about their home during the monthly meetings that are held and minutes of these are recorded. Systems are in place to obtain people and their families/ representative’s feedback about aspects of the service. Observations supported that the manager and staff have worked hard to implement the new documentation and to make it accessible to people. All staff spoken to were clearly motivated and committed to ensuring people had fulfilling lives and positive experiences. Through the provision of meetings and discussions the manager and staff team identify ways that they can improve and develop the service in the best interests of the people who live there. The staff spoke positively about the Registered manager and described her as “supportive, approachable providing effective leadership and direction”. They said that she works alongside them and advises them on any issues raised. The self-assessment and a sample of the health and safety systems and service records confirmed that the building was a safe place for people to live. Ashwood Avenue DS0000068816.V365547.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 3 2 3 3 3 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 3 25 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 X X 3 x Ashwood Avenue DS0000068816.V365547.R01.S.doc Version 5.2 Page 26 No 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 YA20 Regulation 13 (2) Requirement The storage for controlled drugs must comply with the royal pharmaceutical requirements. This is to ensure medication is stored in accordance with the law. Timescale for action 01/09/08 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 YA3 Good Practice Recommendations The admission records should be reviewed to incorporate the following areas of diversity: race, gender identity, disability, sexual orientation, age, religion and belief. These areas should be completed for each resident. Staff should be given the opportunity to attend training in makaton 2. YA32 Ashwood Avenue DS0000068816.V365547.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Ashwood Avenue DS0000068816.V365547.R01.S.doc Version 5.2 Page 28 - 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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