Inspection on 07/03/07 for Autumn Vale

This inspection was carried out on 7th March 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Autumn Vale 19/01/09

Autumn Vale 06/03/06

Autumn Vale 29/06/05

Similar services:

21 High Street

Vale House

Chestnut Walk

The Old Vicarage

Cherwood House Care Centre

Ashley House

Ascot Nursing Home

Fountain View

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Autumn Vale The Circle 26 Clarendon Road Southsea Portsmouth Hampshire PO5 2EE Lead Inspector Nick Morrison Unannounced Inspection 7th March 2007 10:30 Autumn Vale DS0000062949.V327549.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 Autumn Vale DS0000062949.V327549.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 Older People and 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. Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Autumn Vale Address 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) The Circle 26 Clarendon Road Southsea Portsmouth Hampshire PO5 2EE 02392 826034 Lutchmy Care Services Mr Bhimsen Seedeehul Care Home 26 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (26), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (26) Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in MD category must be at least 30 years of age Date of last inspection 6th March 2006 Brief Description of the Service: Autumn Vale is a detached property close to Southsea shopping precinct. The building is a Grade II listed property, designed by architect Thomas Owen. The home provides accommodation and care for up to 26 male and female service users aged 30 years or more with a mental disorder. This does not include service users with dementia.The home is close to Southsea promenade and Southsea common, as well as Southsea shopping precinct. The home is owned by Lutchmy Care Services and the Registered Manager is Mr. Bhimsen Seedeehul. Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report represents a review of all the evidence and information gathered about the service since the previous inspection. This included a site visit that occurred on 7th March 2007 and lasted six hours. During this time the Inspector toured the premises, looked at service users’ files and met with five service users. An in-depth interview took place with three service users and interaction between staff and service users was observed. All records and relevant documentation referred to in the report was seen on the day of the inspection visit. The Inspector spoke with the management team and staff on duty on the day. What the service does well: 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. Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): YA 2 / OP3 and OP6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from having their needs assessed prior to moving into the home. EVIDENCE: Service users’ files showed records of assessments that had been completed by the manager prior to them moving into the home. The assessments were comprehensive. The Manager, Care Managers, Community Nurses, service users and their families had all been involved in the assessment process. All Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 8 assessments contained review dates and they were all reviewed according to the dates identified. Before admission to the home, service users are given the opportunity to stay for meals and then to stay for the day, before being offered the opportunity of a trial stay. This process is varied for individuals depending on their needs and wishes. The home does not provide intermediate care. Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): YA 6, YA7, YA9, OP7, OP14 and OP33 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from having clear individual plans and risk assessments in place, which are kept under regular review, and from support to take decisions and risks appropriate to their development. EVIDENCE: Service users’ files showed that they all had care plans in place that had been devised in response to the initial assessment with input from the service user. There was a clear system in place for monitoring the care plans and they were Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 10 reviewed monthly as well as being updated as and when necessary. Individual care plans were also discussed between the staff team on a regular basis during shift handover meetings. Service users spoken with were aware of their care plans and understood what care and support they were receiving in the home. Observation during the course of the inspection visit showed that staff were aware of care plans for individuals and supported people according to their care plans. This included assisting and supporting service users to make their own decisions with the amount and kind of support their care plan identified as necessary. Service users spoken with said they felt they had sufficient control over their own lives. Risk assessments were well recorded and were updated at regular intervals along with the care plans. The home had a very positive approach to managing risks with service users. All potential risks were identified and measures put in place to decrease the likelihood of unwanted occurrences. Service users spoken with confirmed they had been involved in writing their own risk assessments and identifying measures to be put in place to decrease the likelihood of unwanted occurrences. The specific support each service user required in managing risks was recorded clearly and staff observed on the day of the inspection visit worked according to the risk assessments. Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 12 YA 12, YA13, YA15, YA16, YA17, OP10, OP12, OP13 and OP15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from being part of the community and are involved in varied activities. They also benefit from regular contact with their families and have a healthy diet. EVIDENCE: The home had previously had people coming into the home to provide activities for service users, but people living in the home stopped attending the sessions and they no longer occur. The home had undertaken some consultation with service users about the kind of activities they would like to be involved in and efforts are no being made to support service users in those activities. Service users spoken with on the day of the inspection visit said they felt they had sufficient activities and stimulation offered to them. Current activities included going to the pub to watch the football, going to the café for breakfast, skin and beauty treatments, going to a local club, newspapers available in communal areas, games such as chess and dominoes and going to church. Service users were also supported to maintain and develop independence by being involved in household activities such as setting the table, making beds and preparing drinks and snacks. Service users were encouraged and supported to maintain contact with their friends and families. One service user’s boyfriend was visiting at the time of the inspection visit and other service users spoken with said that staff in the home supported them to visit their families. The management team saw this as a very positive thing and did all they could to support service users maintain contact with their families. The food served in the home was very good and service users provided unsolicited positive comments to the Inspector about the quality of the food. One service user said “we eat like lords and ladies here.” Service users were consulted about what food was going to be on the menu and the management team were also keen on introducing new and different dishes to service users. Menus showed that fresh ingredients were used and good records were kept of all the food provided. All service users spoken with said that the quality and quantity of the food was excellent. The management team were keen that food was served to service users in a proper and respectful manner. They had high standards based on the kind of standards found in restaurants. Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): YA18, YA19, YA20, OP8, OP9 and OP10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from having their health and support needs met appropriately and are protected by the home’s medication policies and practices. EVIDENCE: Service users spoken with were happy about the personal care they received. Staff spoken with said they were clear about what support each person required. Care plans and records demonstrated that service users’ healthcare needs were regularly monitored and that they were supported to access Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 14 relevant healthcare services as necessary. The home had some good work in offering support to service users to stop smoking and one service user was very proud of the fact that she has now stopped smoking altogether. Records were kept of all medical appointments along with actions required as a result. Service users confirmed that staff in the home supported them to attend medical appointments whenever necessary. The home had a comprehensive medication policy in place which staff were aware of. All staff involved in administering medication had received relevant training and said they understood their responsibilities within the process of administering medication. All medication was appropriately stored in a medication cabinet. Medication records were accurate and up-to-date. Information on potential side effects of all medication used in the home was kept and shared with staff. The home liaised regularly with the pharmacists over medication issues in the home. Service users were able to administer their own medication, subject to a risk assessment, but, at the time of the inspection visit, no service users did so. Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): YA22, YA23, OP16, OP18 and OP35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from a clear complaints policy and were protected by the home’s abuse policies and practices and had their financial interests protected. EVIDENCE: The home has an adult protection policy in place to ensure that service users are protected from any kind of abuse. Staff had received training on identifying and responding to instances of suspected abuse and those spoken with were clear about the relevant issues and their responsibilities in this area. There was also a clear whistleblowing procedure in place that staff and service users spoken with were aware of. There was a clear complaints policy which service users and staff were aware of. There had been one complaint, which was an issue between two service users. This had been dealt with formally through the complaints procedure and had been responded to effectively in a timely manner. Records were kept of the complaint, the process of dealing with it and the outcome. Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 16 Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): YA24, YA30, OP19 and OP26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a safe and clean home. The home will be more comfortable when the building work has been completed. EVIDENCE: Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 18 The home is currently undergoing extensive building works to make significant and needed improvements to the house. There is a four-phase plan of work to improve all communal areas as well as the laundry area and the outside of the building. The building work has a temporary effect on the comfort of service users, but all service users spoken with were clear about the work going on and about what improvements were being made. Currently service users smoke in a room upstairs, but this is planned to move to a garden room when the building work is completed. The home is kept as clean as possible with the building work going on. Service users’ rooms were very clean and communal areas were maintained to a good standard. Hygiene is well managed within the home. Part of the building work will result in a new, purpose-built laundry. The home has good hygiene practices in place and there were no hygiene issues identified during the inspection visit. Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): YA32, YA34, YA35, OP27, OP28, OP29 and OP30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from being supported by competent, trained staff and are protected by the home’s recruitment policies and practices. EVIDENCE: Rotas showed that sufficient staff were on duty at all times in the home. Service users spoken with felt that were sufficient staff and spoke very highly of the staff who supported them. Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 20 There were five hundred hours of care staff input per week. This included three care staff on duty throughout the day and two waking staff during the night. In addition there is a chef , a cleaner, an administrative assistant and three managers. During the inspection visit the Inspector observed staff interacting with service users in a very relaxed and supportive manner. The approach of staff observed on the day was wholly positive. They demonstrated that they understood the needs of service users and were skilled in communicating effectively with service users and supporting their personal development. Staff training records were good and showed that staff are able to access a wide range of training opportunities. Good, clear records were kept of all staff training. Staff spoken with said that the quality of training within the home was good and that it was quite freely available. They felt that the organisation supported them well in having the skills to do their job. All staff were encouraged and supported to undertake NVQ training. Training needs were identified through annual appraisals. Staff interaction with service users in the home was extremely good and demonstrated that staff receive very good training in communication, dealing with difficult behaviours, supporting service users to be in control of their own lives and encouraging personal development. Staff records showed that all necessary pre-employment checks were carried out on each member of staff prior to them beginning work in the home. Service users had begun to be involved in the staff selection process so that their views could be taken into account in appointing staff. Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): YA37, YA39, YA42, OP31, OP33, OP35 and OP38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 22 Service users are protected by the home’s Health and Safety policies and practices. Their views are fully considered within the home’s quality assurance processes and the service is consistently managed. EVIDENCE: The home is family run with Mr Seedeehul being the Registered Manager and his wife and son assisting him. As the Registered manager, Mr Seedeehul has demonstrated that he has the skills, qualification and experience to manage the home. All three members of the family are involved in the home on a dayto-day basis. There were a range of quality assurance methods employed in the home including regular monthly visits from the provider, regular questionnaires for service users, families and other professionals, input from service user meetings as well as individual service user input through the care planning process and through daily activities, behaviour and discussions. The quality assurance system continues to develop and improve and is used to inform the development of the service. The management approach was to include service users fully in all aspects of service development and those service users spoken with had a very clear idea about what was happening in the home and what was planned for the future. All staff had received health and safety training and workplace risk assessments were in place and regularly reviewed. There were extensive risk assessments in place at the time of the inspection visit due to the building work that was going on. Service users had been fully involved and fully briefed about the building work and the management team had ensured they had dealt with potential safety issues as well as the dignity and potential anxiety of service users. They had employed a consultancy company to assist with this process and had regular meetings with service users and introduced them to all the builders. During the inspection visit service users were observed chatting to and having jokes with the builders. The situation was regularly monitored and records were kept to demonstrate this. All fire equipment was regularly checked and records were kept. Staff fire training was up to date and there were records of regular fire drills. All staff had up to date health and safety training and were clear about their responsibilities within this. There were no health and safety concerns highlighted on the day of the inspection visit. Incidents and accidents were recorded and monitored and there was evidence that alterations to the building had been made, where necessary, in response to these. Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 23 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. Where there is no score against a standard it has not been looked at during this inspection. 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 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 2 25 X 26 X 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 Standard No Score 37 3 38 X 39 3 40 X 41 X 42 3 43 X 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 Autumn Vale Score 3 3 3 X DS0000062949.V327549.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Autumn Vale DS0000062949.V327549.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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