CARE HOME ADULTS 18-65
Astor House 12 Oakwood Avenue Purley Surrey CR8 1AQ Lead Inspector
Barry Khabbazi Key Unannounced Inspection 9th June 2006 9:00am Astor House DS0000025750.V300061.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 Astor House DS0000025750.V300061.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. Astor House DS0000025750.V300061.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Astor House Address 12 Oakwood Avenue Purley Surrey CR8 1AQ 020 8763 0267 020 8668 2471 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) Surrey Oaklands NHS Trust Ms Elisabeth J Murray Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Astor House DS0000025750.V300061.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 8th December 2005 Brief Description of the Service: Astor House is a large detached house situated in a residential road in Purley. The property is keeping with the other houses on the road. The town centre has bus and train services, a shopping centre and a Tesco superstore in addition to other services. The home has its own minibus. There are ramps to the front and back to facilitate wheelchair access to the home and rear garden. There is a lift serving the bedrooms on the first floor. Astor House has been designated as a home for more elderly service users who have a learning disability and may also have a physical disability. As the service users are over 65 years old, the inspector has advised the registered manager to apply in writing for the registration to be amended to reflect this situation. The home is therefore applying for its registration to be changed from Younger Adults to Older People. The home is reminded that it must meet Older Person Standards now. These Standards were also considered in this report and will be looked at in full at the next inspection. Fees for this home are from £1121.81 per week. Astor House DS0000025750.V300061.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This home meets {and exceeds in some cases} most of the National Minimum Standards and has demonstrated many areas of good practice. All of the Commission’s service user and relative surveys have also confirmed this view, with only positive comments about the home being received to date. Where shortfalls have been identified these are of a minor nature and the manager has proven committed to fully meeting all areas and exceeding them where possible. This unannounced key inspection focused on all the key standards and following up on previous requirements. During this inspection the service users and some of the staff were met, the manager was interviewed, and records, policies, care plans, and the building were examined. What the service does well:
It was reassuring to see that there was a calm, caring and relaxed atmosphere in the home, despite the amount of morning personal care, food preparation and assistance with feeding required, and the disruption of an unannounced inspection. This has always been the case during inspections at this home. The move to person centred planning is seen as good practice as this ensures care needs are identified from the service users’ perspective. A few days before a previous inspection, the service users asked staff for a barbeque instead of the planned meal for that day. The home was flexible and accommodated this. In addition, at this inspection as the sun was shining, the plans for the day were changed to activities that would take advantage of the nice day. The home’s willingness and ability to respond to service users’ wishes in a spontaneous manner, and to change plans at the last minute in the interests of the residents is to be commended. Staff attend hospital with service users and stay with those admitted. This provides continuity and reassurance for service users, and improves the overall level of hospital care by staff being able to communicate effectively with the service user. It was seen as good practice that medication training occurs annually and additional annual training occurs in ‘as and when medication’, and also in diazepam usage. The residents’ needs regarding terminal care and following death are met well and this Standard is exceeded for the following reasons: During these periods, relatives can visit at any time day or night if wanted by the resident; if and when no relatives are present, a staff member is available to provide a continual vigil if wanted; the home maintains contact with relatives following death of a resident; funerals have occurred at the home; the home has provided transport to assist relatives to attend funerals; and although residents have the right to die at their home, where there is a medical reason for a hospital admission at these times, the home sends staff to the hospital so that the resident does not have to be alone in their final moments.
Astor House DS0000025750.V300061.R01.S.doc Version 5.2 Page 6 Good practice continued The previous report recorded that ‘the home gave the impression of a clean and hygienic home. The building was clean and tidy and rooms were generally free of offensive odours.’ It was good to see that this was also the case at this unannounced inspection. The home is particularly hygienic and clean. As this has been seen to be the case on a number of unannounced inspections, this area can now be assessed as continuing good practice under Standard 30. What has improved since the last inspection? What they could do better:
Although the Service Users Guide has been much improved and is now also more accessible, it does not contain the views of the residents. This is important so that new residents are clear about how other residents feel about living in this home. The new care plans need to contain all the information required under Standard 6 or a reference to where this information is documented. This is needed so that information regarding all the needs of a resident can be easily and efficiently accessed. Although reviews are occurring, this was not well recorded. Clear records of this are needed to ensure that the residents needs are reviewed regularly. Residents do not receive all the paid holidays they are entitled to. Each resident should be offered a seven-day holiday paid for by the home as a part of the contracted price. This would facilitate more funding and additional holidays for residents that they do not have to pay for.
Astor House DS0000025750.V300061.R01.S.doc Version 5.2 Page 7 The completion of staff induction and foundation training within Sector Skills Council training specifications is not being met satisfactorily. This could also affect the home’s ability to meet all a resident’s needs. Although progress has been made with regards to the home to implementing a quality assurance system and an annual development plan, with both involving residents, more work in this area is required. Although not having this fully in place could limit the involvement of the residents and relatives, both residents and relatives have commented about being involved in decision making in practice. 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. Astor House DS0000025750.V300061.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 Astor House DS0000025750.V300061.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Although the home provides most of the information needed for potential residents to make an informed decision about moving in to the home, the residents do not have all the information they need. There have been no new service users to facilitate re-assessing Standard 2 on this occasion. However this Standard has been previously met. EVIDENCE: The Statement Of Purpose contains all the elements required, including the size of the bedrooms and communal rooms, the number of bathrooms and toilets, the experience of staff, and the fire procedures. The last inspection report contained a requirement for the service users guide to contain the views of the service users. Since the last announced inspection, the service users guide has been made more accessible with the use of symbols and pictures and the home has sought the views of the service users through questionnaires. This information now only needs to be collated and included in the service users guide. The existing requirement will remain until fully met.
Astor House DS0000025750.V300061.R01.S.doc Version 5.2 Page 10 There have been no new service users to facilitate re-assessing Standard 2 on this occasion. However this Standard has been previously met. Astor House DS0000025750.V300061.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Plans of care are now more holistic although they do need to be referenced to other documents recording other care needs so that all needs can be easily made known to staff. Service users are supported to make decisions about their lives. Service users are appropriately supported to take risks as part of their independent lifestyle and risk assessments now contain all the information required to facilitate minimising restrictions of liberty for the residents. EVIDENCE: The new plans of care are now more holistic. However, they do not contain all the information required under Standard 6 and 2.2. The missing information was recorded elsewhere in service users’ file. This is acceptable only if references are in the care plan which direct staff to where they can find the other information required. The following requirement is therefore now set to address this.
Astor House DS0000025750.V300061.R01.S.doc Version 5.2 Page 12 The new care plans must cover all the elements required under Standard 6 or record where this information is to be found if held in other documentation. There was evidence provided of the frequency of reviews but this was not clearly recorded in files sampled. The following recommendation is now set to address this: Records of reviews should be recorded more clearly. Much improvement has been made in producing risk assessments where restraints or restrictions of liberty are pre-planned. These are now available for all areas required. These now contain all the information required under this Standard, specifically what training or other options have been explored before a restraint or restriction of liberty is applied. Astor House DS0000025750.V300061.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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. Service users have the opportunity for self-development, are part of the local community and are able to take part in appropriate activities. Service users do engage in appropriate leisure activities and holidays, although the residents do not receive all the placing authority funded holidays they are entitled to. Residents are well supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. The food provided is sufficient in quantity, and it is sufficiently nutritious. This is important to ensure good health. EVIDENCE:
Astor House DS0000025750.V300061.R01.S.doc Version 5.2 Page 14 Basic money awareness training occurs for two of the residents during shopping trips. Access to activities is provided at the home and at the daycentres that are attended by all the residents. Access to the local community is assisted by the home having its own transport. The local pubs, parks, restaurants, cafes, church, and shops are accessed. Staff are available to support residents while accessing the community and this occurs about three times a week in summer and occurs in the evenings as well as during the daytime and at weekends. Some residents attend a local clubs. All residents are on the electoral register. A few days before a previous inspection, the service users asked staff for a barbeque instead of the planned meal for that day. The home was flexible and accommodated this. In addition at this inspection as the sun was shining, the plans for the day were changed to activities that would take advantage of the nice day. The home’s willingness and ability to respond to service users’ wishes in a spontaneous manner, and to change plans at the last minute in the interests of the residents is to be commended. Residents are offered a holiday with £150 of extra staffing hours. The residents are currently required to pay for the cost of the holiday themselves. The following previous recommendation remains regarding this: Each service user should be offered a seven-day holiday paid for by the home as part of the contracted price. The manager has stated that the home has a good relationship with their neighbours and they are invited to any social events arranged by the home. There is also now a link with primary school for harvest festival and plays etc. Activities within the home include: Barbeques, tea parties, skittles, dominoes, board games and music. In-house activities suited to an older service user group such as reminiscence, hand massage and music therapy occur. The staff team at the home also arrange day trips and outings for the residents. Astor House DS0000025750.V300061.R01.S.doc Version 5.2 Page 15 There is an open visitors policy and the home just ask that visitors phone to ensure their family member or friend is going to be in before they visit. Visitors can be seen in any of the home’s communal areas as well as the service users’ bedrooms. Family and friends are invited to any social events held at the home as well as reviews. At Christmas the home arranged a “high tea” for friends and family. The home has a key worker system and it is part of their role to keep parents and carers informed of their progress. The house rules and daily routines are as flexible as possible, bearing in mind the weekday commitments of the residents. At the weekends there is more flexibility with breakfast and bedtimes. Residents are encouraged to help out with some household tasks such as clearing the table or taking out the bins. The residents are given a choice of having keys to their bedrooms and the front door of the home. The residents have not taken up this option and the reasons are recorded on their personal files. The home menus are seasonal and based on the likes and dislikes of the home’s residents. The Trust dietician visits the home on a regular basis to check the menus for nutritional value. When a resident has an alternative meal a record is kept of what they have eaten. The inspector was previously invited to join in the main meal of the day, and was again pleased to observe a jovial and friendly atmosphere between staff and residents. Astor House DS0000025750.V300061.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, and 21. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents’ personal care needs and physical and emotional health needs are met well by this home. This ensures that the residents’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. Residents’ medication is also well managed to ensure maximised good health. The residents’ needs regarding terminal care and following death are met well and this Standard is exceeded. EVIDENCE: Astor House DS0000025750.V300061.R01.S.doc Version 5.2 Page 17 The service user group all need assistance with their personal care and where possible a person of the same sex offers support with personal care. Personal care is provided in private, and timings of this are also flexible, for example residents can have a bath when they are not booked in for this. The residents were observed at this inspection to be treated with dignity and respect during assistance with feeding and moving. The residents choose their own clothes and staff support service users with shopping for personal items of clothing or toiletries where required. The service users are registered with a local G.P. They are able to access community health facilities such as opticians, chiropodist and district nurses as required. Service users are supported to attend outpatient appointments and other medical appointments as required. The home has a copy of the British Medical Association guide to medication in place. Medication profiles and medication administration record sheets were seen in records sampled. Medication is kept securely in a locked metal cabinet fixed to the wall. The Trust has a policy on the administration of medication and also provides accredited training in this area. Staff attend hospital with residents and stay with those admitted. This provides continuity and re-assurance for residents, and improves the overall level of hospital care by staff being able to communicate effectively with the resident. It is seen as good practice that medication training occurs annually and additional annual training occurs in ‘as and when medication’, and also in diazepam usage. The residents’ wishes regarding terminal care have now been sought and recorded. This Standard is exceeded for the following reasons: During these periods, relatives can visit at any time day or night if wanted by the resident, the home maintains contact with relatives following death of a resident, funerals have occurred at the home, the home has provided transport to assist relatives to attend funerals, although resident have the right to die at their home, where there is a medical reason for a hospital admission at these times, the home sends staff to the hospital so that the resident does not have to be alone in their final moments. Astor House DS0000025750.V300061.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Complaints are generally managed well and there were no complaints since the last inspection. Service users are protected from abuse or self harm through the home’s protection policies and procedures and by these being known. EVIDENCE: The last inspection report contained a requirement for all versions of the complaints procedure to clarify that the Commission can be contacted at any point of a complaint, and not following the internal stages being exhausted. This has now occurred and this requirement is now met. The home has a copy of Croydon’s Vulnerable Adults Policy and training in this area is mandatory. The last announced inspection report recorded that the home has a “Responding to Aggression and Violence” policy and procedure, which states that physical restraint, should only be used as a last resort and should be recorded. A new corporate Whistle Blowing Policy and a local Wills Policy has been devised and staff were aware of these. Astor House DS0000025750.V300061.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, and 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The environment and furniture generally met the residents’ needs, and the environment promotes the residents’ well being. Service users’ bedrooms promote independence and contain all the furniture required. The home is particularly hygienic and clean, homely and comfortable, this environment therefore facilitates the residents’ health and emotional wellbeing. EVIDENCE: Astor House DS0000025750.V300061.R01.S.doc Version 5.2 Page 20 The home is a detached house situated in a residential area in Purley close to transport links. The home is decorated and furnished in a domestic style and free from offensive odours. The outside of the home has been re-decorated since the last inspection. There is a ramp providing access to the front of the home and is a garden to the rear that has level access. Maintenance for the home is provided on an as required basis by The Trust Works department. The overall condition and décor of the home was reasonable. The path in the back garden was previously uneven but has since been levelled to promote safe access for the residents. Residents’ rooms were individually decorated and rooms had been individualised by the residents. The bedrooms on the first floor are accessed via a passenger lift. The last inspection report recorded the following: Residents’ rooms do not contain all the furniture required. This may be because a resident has chosen not to or because of risk. This must be recorded to ensure that residents have all the furniture they are entitled to. Reasons for residents not wanting specific pieces of furniture are now recorded and the requirement regarding this is now met. The home has two accessible baths, and has three separate toilets. The previous report recorded that ‘the home gave the impression of a clean and hygienic home. The building was clean and tidy and rooms were generally free of offensive odours.’ It was good to see that this was also the case at this unannounced inspection. The home is particularly hygienic and clean. As this has been seen to be the case on a number of unannounced inspections, this area can now be assessed as continuing good practice under Standard 30. Astor House DS0000025750.V300061.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, and 35. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The residents are supported by appropriately qualified staff which raises the quality of staff and their practices. The home’s recruitment procedures protect the residents through vigorous staff vetting. Although there has been progress in implementing the induction training programme, the home has not completed staff foundation training within Sector Skills Council training specifications and timescales. This could also affect the home’s ability to meet all a resident’s needs. EVIDENCE: There are 17.45 Full Time Equivalent Staff, 11 of which have NVQ 2, two of these also have an NVQ 3 and another 1 of these has a NVQ 4. This exceeds the minimum of 50 of qualified staff required under Standard 32 and therefore this Standard is exceeded. Astor House DS0000025750.V300061.R01.S.doc Version 5.2 Page 22 All elements of Schedule 2 {staff files} are now kept securely on site and are available for inspection. This includes CRB checks, references and records of staff disciplinary action. There have been no new staff since the last inspection where staff files were examined {See October 2005 inspection report for details}. At that time all the information required was present and this Standard was met. As no new staff had started staff recruitment files were not re-examined at this inspection. All staff recruited since April 2002 undertake a comprehensive induction. This does not currently meet the topics and timescales required to be covered in the first six weeks induction and following six month foundation training as specified within Sector Skills Council workforce training targets. A requirement remains in force regarding this. Astor House DS0000025750.V300061.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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. The home is managed by an experienced and well qualified manager who ensures a quality service. Although progress has been made with regards to the home to implementing a quality assurance system and an annual development plan, with both involving residents, more work in this area is required. Although this could limit the involvement of the residents and relatives, both residents and relatives have commented about being involved in decision making in practice. More diligence is required in maintaining maintenance schedules as water tests, and gas safety certificates were not available. This could put the residents at risk if left unchecked. EVIDENCE: Astor House DS0000025750.V300061.R01.S.doc Version 5.2 Page 24 The home has a registered manager who is a qualified first level nurse and has over twenty-five years experience of working with people with learning disabilities. As well as a nursing qualification the manager also has a Certificate In Management Studies and has the Registered Managers Award 1 and 2 to level 4 Although progress has been made with regards to the home implementing a quality assurance system and an annual development plan, with both involving residnts.The results of the user/relatives satisfaction surveys need to be incorporated into the annual development plan that is open to the residents, to fully involve the residents and allow measurement of achievement in improving quality. The requirement rewarding this therefore remains in force. The last inspection report recorded that the 5-year wiring certificate was out of date and a requirement for an up to date certificate was made. This has since been received and that requirement is now met. The last inspection report recorded that the glass doors from the lounge to the dinning room may not be safe. The manager was asked to check if safety glass or safety film is fitted. This has occurred and the door glass is safe. The requirement regarding this is now met. All of the health and safety policies and procedures relevant to this Standard have been seen to be present. Moving and Handling, Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. Control Of Substances Hazardous to Health policies and data sheets are present and all these items are locked in the storage cupboard. The testing of systems required in Standard 42 were all also present except bacterial analysis and testing of the water supply and the gas safety certificate. The following new requirement is now thefore set. A copy of the gas safety certificate and the water testing certificate must be sent to the Commission. Astor House DS0000025750.V300061.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 2 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 4 33 x 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 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 4 3 x 2 x x 2 x Astor House DS0000025750.V300061.R01.S.doc Version 5.2 Page 26 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA1 YA6 Regulation 5 123 22 Requirement The Service Users Guide must contain the views of the service users. The new care plans must cover all the elements required under Standard 6 or record where this information is to be found if held in other documentation. All staff recruited since April 2002 must undertake a six weeks and six month foundation training to Sector Skills Council workforce training targets. The home must pull together its Quality Assurance tools into a structured Quality Assurance system that makes the service users central to the process. The home must also introduce an annual development plan that is open to the service users, to allow measurement of achievement in improving quality. {previous timescale of 1/12/2004 not met} A copy of the gas safety certificate and the water testing certificate must be sent to the Commission. Timescale for action 01/08/06 01/08/06 3. YA35 181a c 01/10/06 4. YA37 24,1,2,3 01/08/06 5 YA42 12 01/08/06 Astor House DS0000025750.V300061.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard YA14 YA6 Good Practice Recommendations Each service user should be offered a seven-day holiday paid for by the home as part of the contracted price. Records of reviews should be recorded more clearly. Astor House DS0000025750.V300061.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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