Inspection on 09/07/08 for Azalea House 1

This inspection was carried out on 9th July 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Azalea House 1 24/10/08

Azalea House 1 16/08/07

Azalea House 1 07/09/06

Azalea House 1 15/05/06

Similar services:

Chesham House

Argyll House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Azalea House 1 71 Winifred Road Bedford MK40 4EP Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 9 & 16th July 2008 12:45 th Azalea House 1 DS0000066699.V366935.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 Azalea House 1 DS0000066699.V366935.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. Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Azalea House 1 Address 71 Winifred Road Bedford MK40 4EP 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) 0870 609 2432 no email as at 2.7.07 www.minstercaregroup.co.uk Minster Pathways Limited Jan West Care Home 4 Category(ies) of Learning disability (4), Mental disorder, registration, with number excluding learning disability or dementia (4) of places Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16/08/07 Brief Description of the Service: Azalea Services are two privately owned care homes situated in a residential street on the west side of Bedford. The two adjacent houses operate in conjunction with each other. House 1 is registered for 4 service users who have a diagnosis of learning disabilities and mental health needs; house 2 is registered for 3 people in the same category. The purpose of the service is to offer appropriate support for service users, including developing or maintaining their independence skills. The house is a domestic property and offers single bedrooms, a lounge; bathing facilities, staff sleeping room, a dining room, and a kitchen. There is a rear garden at the back of the two homes, fenced off separately. The common office to both the homes is located in an extension in one of the back garden. The house is located approximately one mile from the town centre and within walking distance of local shops, pubs, and transport links. The fee quoted by the manager was in the range of £700-£1300. Azalea House 1 DS0000066699.V366935.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 this service is 1 star. This means the people who use this service experience adequate quality outcomes. This is the report of the unannounced inspection carried out on 9th and 16th July 2008 by Pursotamraj Hirekar over 11 hours 40 minutes. The senior staff member on duty coordinated the inspection on 9th July whereas the area manager coordinated the inspection on 16th July 2008. The method of inspection included study of care plans, risk assessments, staff deployment duty rota, relevant care delivery documents, discussions with staff and people who use the services, discussion with visiting family members, observations of staff and people interaction and partial tour of the building. Written response received from the area manager in response to the inspection feedback and survey response from people who use the service and staff is included for analysis and preparation of this report as well. What the service does well: What has improved since the last inspection? What they could do better: The registered manager must explore and make further improvements to develop individual specific activity plans that meet their lifestyle needs. Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 6 The registered manager must ensure that the medication receipt, storage, administration, stock, and returns are in order and appropriate records are maintained to avoid any potential confusion or medication errors. The registered manger must make timely referrals to the safeguarding team of the social services to ensure the people are protected always. The registered manager must ensure that all staff recruitment checks and records are upto date and are held on their files. The registered manager should review and update all policies and procedures wherever necessary and share with the staff. The management should make a provision for one staff member recruitment process; supervision and appraisals are managed by other senior staff to avoid any potential conflict of interest. The staff should continue to keep the bedrooms of people who use the service and all communal areas clean, tidy, and free from any offensive odours always. The registered manager should involve the people and or their representatives in the care planning and review process of each individual person to ensure that their needs are met. The registered manager should arrange for each individual person to have a written contract that detailed services offered and fees charged. The registered manager should involve the people and or their representative in the needs and risk assessments The registered manager should provide statement of purpose to the existing and potential people who use the service in an appropriate format that suit their communication needs 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. Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. People who use the service receive information about the home. However, the people or their representatives are not involved in the assessment process to ensure their needs are met. EVIDENCE: Information about the home is contained in the statement of purpose and that was comprehensive and reflects the current services, offered to prospective and existing people who use the service. The process for moving into the home, facilities, and choices is detailed including the information on how to contact independent advocacy and complaints process. This is given to people when they move to the home as part of the admission process. However, it was found that, the information was set out in small fonts and not in an easy read style, to suit the communication needs of 2 persons who was case tracked on this inspection. There has been a new admission to the service since the last inspection. The care file for the people contained comprehensive pre admission assessments carried out before the admission to the home. This ensures the staff are able to meet care and support needs of that individual. 2 people using the service Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 9 were case tracked. The home had undertaken a full assessment of needs for each of them. However, there was no evidence provided that the method of assessment had involved the person who used the service, the family, and or their representative. The people and a visiting family member spoken to further confirmed this. There was evidence that the home had regularly reviewed the assessments of need. There was no evidence provided that the people who used the service whose lives were tracked had written contracts with the home that included a statement of the terms and conditions that detailed the range of services offered and the fees, which had been signed by them or their representative, and the representative of the home. These issues were discussed with the area manager as part of the inspection process, who confirmed in writing to us that contract, service user guide, and statement of purpose would be produced in an easy ready format. Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. The home had developed detailed care plans based on the needs and risk assessments of the people who use the service. However, the people or their representatives are not involved in the care planning process to ensure their needs are met. EVIDENCE: The care documents of 2 people using the service were seen which, included risk assessments, independence assessment, goal plan, support plan, and behaviour management plan that outlined the individual need with regard to their personal care needs support, health care, daily routines, domestic tasks, cultural issues, finances, and social interests. The information was holistic and from the view of the people using the service in relation to their choice of lifestyle, needs and interests. However, there was no evidence that the people and or their representatives were involved in the care planning and review process, to ensure that the assessed needs were met. A copy of the care plan was shown to a person and when asked, have you seen this care plan, he said, Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 11 he has ‘not seen and is not aware of what is written in the plan’. Another person said ‘I do not know’. The third person said’ I have signed but haven’t read it, need big size font to read’. In response to the inspection feedback session, the area manager confirmed with us writing that all staff will be provided training in person centred planning and care plan would be developed with the involvement of the people and or their representatives and developed in an appropriate format that would enable them to understand. These various plans were regularly reviewed through an established process of monthly goal monitoring and as and when the need arouse and the changes were reflected in their care plan. For example a person travel assessment has been reviewed and this was reviewed and reflected in the care plan along with guideline for staff to follow. And for another person, care plan was updated to reflect changing needs with clear guidelines for staff with regard to managing negative behaviours positively and authoritatively. The staff working was aware of the changes to the care plan of the person. Information was written to help staff to provide the right level of support in relation to promoting independence and skills for daily living such as personal care, domestic tasks, and accessing the community. People using the service said staff knew their routines and choices. The daily routines presented in the support plans reflected in the daily reports of the people using the services. Observations made indicated the relationship between people using the services and staff is relaxed, friendly and polite, showing respect to each other when they are talking or expressing a view. The staff on duty said people make their own decisions or are supported through conversation to make their own decisions. Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. The home need to explore and make further improvements to develop individual specific activity plans that meet people who use this service, their lifestyle needs. EVIDENCE: Staff members on duty said people moving to the home are supported to continue participating in daily social and community activities. Information about each individual’s daily, social and community activities are detailed separately for morning, afternoon, and evening in the assessment and are included in their care plan. Most of the people who use the service were taken out for a week long day trips, on their return the people spoken to have said that they have enjoyed the day trip and each one of them were keen, happy and excited to share with Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 13 us their experience of various things that they have seen and felt happy about from the day trips. One person had read through a 3-page note of her wonderful experience from the day trips. However, in the day-to-day routine apart from day trips, most of the people spent their time in household chores, watch TV, and relaxing. The current activities managed by the home do not provide enough stimulation and help develop independent lifestyles for the people using the service. The home needs to further develop variety of inhouse and outdoors activities that stimulate and engage people to achieve independent life skills. This way, the people need encouragement to develop their own initiative and the activities. This was discussed with the area manager as part of the inspection feedback session. The area manager confirmed with us in writing that staff will identify activities in both the home and the wider community to improve the quality of life of people who use the service and weekly activity plan would be developed and closely monitored by the staff and discussed in their individual supervision and appraisal. People were observed interacting with each other and with staff, and their relationships seemed friendly and supportive. The home had a food menu plan that was prepared on a weekly basis, people had the choice of menu, and the food intake was monitored on a weekly basis. The people moved freely between houses and enjoyed that freedom. The people had a designated space for smoking in the rear part of the home and the staffs supported the people to follow. The people who use the service have said that ‘got lovely room, staff are good, they provide help and support when I ask’. People can choose how to spend the evening and weekends, including seeing family. There was evidence that the home supported people who used the service to maintain family links and friendships inside and outside the home, in accordance with their wishes. People who were spoken with, who lived at the home, said that their families and friends could visit at any time supported this evidence. Staff demonstrated a good understanding of the people they key work, recognising if the person is anxious or unhappy, and how to approach them. People using the service spoken to, have said that they have the freedom to make choice of the meals and mealtime. Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. The personal and health care needs of people, who use the service, are provided but further improvements were needed in the area of management of medication records to avoid potential confusion and any medication errors. EVIDENCE: Risk assessments are detailed and include information about personal care, personal hygiene, toileting, medication, domestic tasks, social, and day care activities. The personal and health care needs of the people who use the service are detailed in their individuals’ health care plans, and staff has guidance in relation to the level of support required, if any. Staff, and the people who use the service appeared to have good working relationships. This was supported through the observations made during the interactions, between the people and staff members. Records viewed suggested people received personal support in the way they preferred. Each person who used the service had a key worker and they were each able to identify who this was and they said they were happy with the support received from them. Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 15 The home had made arrangements for the people using the service to maintain contact with family and friends. Care plans detailed emergency contacts and health care professionals involved in their care. The records showed people had regular appointments with the general practitioner, nurse, and psychiatrists. Trained staff administers people’s medication, staff training records, and staff spoken to have confirmed this. The staff on duty demonstrated a good understanding of the medication, people using services take and the importance of having the medication on time. People said they do receive their medication on time. However, on this occasion 2 people’s medication records and reconciliation was carried out and find out that the home had not maintained appropriate records for receipt and returns of medicine and this led to the MAR sheet and the medicines in stock did not match. This was discussed with the staff member on duty and the area manager. The medication policy was provided in detail with guidance for staff to follow but this has been not in practice. The area manager then affirmed that she would take it up with the manager and staff and introduce changes that would avoid potential confusion and any medication errors. This was further confirmed by the area manager in writing to us, post this inspection that a full medication audit will be requested from boots pharmacy and weekly checks will be carried out by the area manager to ensure that receipt, storage, administration, stock returns are in order. Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. Staff are trained and people who use the service have their interests supported by procedures. However, the service needs to make further improvements with regard to timely referrals of incidents to the safeguarding team. EVIDENCE: The complaints procedure was available but not in an easy read style for the benefit of people using services that have communication needs and was not displayed at appropriate places until the inspection feedback was provided. The people using the services indicated that they were aware of how to express concerns about the provision of care provided at the service. A person spoken to say if, “I am not happy, I speak with the manager or my key worker”. Another person said ‘I speak with staff or manager’. The home had an incident of theft at the home. However, safeguarding referral was not made until we informed the manger, who promptly referred to the safeguarding team. This was brought to the attention of the area manager, who confirmed that, the home continues to let us know about things that have happened since our last key inspection and they have shown that they have managed issues well and make referrals to safeguarding team without any delays as well. Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 17 The staff on duty demonstrated an adequate awareness of their role, responsibility, and procedures they are required to follow in relation to any allegation or suspicion of abuse. This was discussed with the area manager as part of the inspection feedback, the area manager had written to us stating that all staff will be retrained in safeguarding policies and manager will be supported in understanding the importance of reporting all safe guarding issues and incidents to the appropriate agencies in a timely fashion. The people can choose to manage their own money if they are able to do so. Records of money transaction were maintained. The staff on duty described the process for recording and handling of money for people, which ensure people are protected. Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. The home needs further development to keep it always clean and tidy to ensure that the people live in a homely and comfortable environment. EVIDENCE: The home was not always clean and tidy, one could smell offensive odours; the staff do their best to keep it clean and tidy despite the difficulties they have with the people who use the service. There is good lighting throughout the home. Individual bedrooms were personalised to suit the choice and taste of the people who use the service. The bedrooms are appropriately furnished and include personal objects as well. One person’s bedrooms was visited bedroom had been personalised with objects that reflected her interests and was clean. Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 19 The people who use the service appeared to be at ease in the home with the staff on duty, choosing to sit in the lounge or going to their bedroom. The home continues to repair and replace items within the home so it remains clean, homely and comfortable environment. The service had carried out fire alarm, door close, fire evacuation, fire doors, emergency lights, fire drill, smoke & heat detection, and water temperature checks. The records that were available at the home, and the staff on duty confirmed this. Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. Staff training, and supervision support the people who use the service. However, further improvements need to be made with regard to staff recruitment records update and staff appraisal. EVIDENCE: The interaction of staff with the people using the service was good; there was good rapport, both verbal and non-verbal communication was used. The key worker was aware of the needs of the person’s routines and how best to communicate with them. The staff recruitment documentation was seen on this inspection; with regard to the details of the staff recruitment practices that include an application form with employment history and any gaps in employment, qualification, references, and an enhanced CRB check. One staff member reference did not match with that of the previous employer and another staff member CRB had a reprimand note and the manager justified this with a written note held on the file. The manager had also carried out staff appraisal for this staff member who Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 21 is related to her. The management should make a provision for this staff member recruitment process; supervision and appraisals to be managed by other senior staff to avoid any potential conflict of interest. This was discussed with the area manager during the inspection feed back session. Post this inspection the area manager had confirmed in writing with us that staff files will be audited and ensured that all information held on staff files are current and regular checks will be carried out to ensure all relevant documentation is held on staff file. The service had the required NVQ level 2 and above qualified staff working at the service. Staff training records showed that staff has received mandatory training, This was supported by staff spoken to, which identified varied training, which they had undertaken. The service had maintained appropriate staff deployment ratio based upon the needs of the people who use this service. Staff on duty, confirmed they received supervision. In the staff supervision, concerns raised by staff are addressed in the best possible way, which benefits the people using the service. Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 People who use this service experience good quality outcomes in this area. We have made this judgment using a range of evidence including a visit to this service. The home has good quality assurance systems and procedures that enable the management to run a well managed home, to promote the quality of life of the people who use the service. EVIDENCE: On discussion with the staff on duty and the people who use the service, the area manager appears to have developed good working relations with the staff and the people living at the home. In response to the inspection feedback, with regard to various outcome groups as detailed in this report, the area manager had sent us an improvement plan detailing how they planned to make Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 23 improvement that benefit the people who use the service. We consider this as a proactive approach to make improvements at the home. The various care documents seen on this inspection confirmed that there are clear roles and responsibilities in relation to the management of the home and staffing. Staff meetings were held, to discuss people’s assessed needs and care delivery, to ensure people’s assessed needs and staff training needs were being met. The home had the quality assurance system and procedure, which ensured that the service had been actively engaged in quality assurance work, to ensure that the people living at the service had their quality of life goals were met. As part of the annual quality assurance system, questionnaires planned to be sent to receive feedback from the people who use the service and their families that would be analysed and the results, used to develop action plan. The action plan shall be used as a reference document to introduce changes and making improvements to the people’s care planning and delivery mechanisms. The home had health and safety risk assessments and monthly checks carried out, these checks help in identifying any concerns to the premises. The policies and procedures were of 2006 dated and the registered manager should ensure to regularly review and update where necessary. This was discussed with the area manager as part of the inspection feedback session, who then sent us a written confirmation that all policies and procedures are currently under review and will be put in place on completion. The people living at the service have regular monthly meetings, in the meetings any issue that surface in the day-to-day operations are discussed and staff responsibilities are identified to action. People, spoken to confirm that, they are encouraged to express themselves about the running of the home, what improvements are made in relation to their accommodation, décor and they can speak with staff at anytime. Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X 2 3 X Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 25 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. Standard YA13 Regulation 16(2)(m) Requirement The registered manager must explore and make further improvements to develop individual specific activity plans that meet their lifestyle needs. Timescale for action 29/08/08 2. YA20 13 (2) 3. YA23 13 (6) The registered manager must 15/08/08 ensure that the medication receipt, storage, administration, stock, and returns are in order and appropriate records are maintained to avoid any potential confusion or medication errors. The registered manger must 15/08/08 make timely referrals to the safeguarding team of the social services to ensure the people are protected always. The registered manager must 15/08/08 ensure that all staff recruitment checks and records are upto date and are held on their files. 4. YA34 19 Azalea House 1 DS0000066699.V366935.R01.S.doc Version 5.2 Page 26 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 YA41 Good Practice Recommendations The registered manager should review and update all policies and procedures wherever necessary and share with the staff. The management should make a provision for one staff member recruitment process; supervision and appraisals are managed by other senior staff to avoid any potential conflict of interest. The staff should continue to keep the bedrooms of people who use the service and all communal areas clean, tidy, and free from any offensive odours always. The registered manager should involve the people and or their representatives in the care planning and review process of each individual person to ensure that their needs are met. The registered manager should arrange for each individual person to have a written contract that detailed services offered and fees charged. The registered manager should involve the people and or their representative in the needs and risk assessments The registered manager should provide statement of purpose to the existing and potential people who use the service in an appropriate format that suit their communication needs 2. YA36 3. YA30 4. YA7 5. YA5 6. YA2 7. YA1 Azalea House 1 DS0000066699.V366935.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 Azalea House 1 DS0000066699.V366935.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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