Inspection on 19/03/07 for Banstead Road South (21)

This inspection was carried out on 19th March 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Banstead Road South (21) 27/11/07

Banstead Road South (21) 23/11/05

Banstead Road South (21) 13/07/05

Banstead Road South (21) 11/02/05

Banstead Road South (21) 06/09/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Banstead Road South (21) 21 Banstead Road South Sutton Surrey SM2 5LF Lead Inspector James O’Hara Key Unannounced Inspection 19th March 2007 09:30 Banstead Road South (21) DS0000007211.V332987.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 Banstead Road South (21) DS0000007211.V332987.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. Banstead Road South (21) DS0000007211.V332987.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Banstead Road South (21) Address 21 Banstead Road South Sutton Surrey SM2 5LF 020 8770 0106 020 8770 0106 max.edward@surreyoaklands.nhs.uk 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 and Borders Partnership NHS Trust Mr Max Anton Edward Care Home 7 Category(ies) of Learning disability (7), Sensory impairment (7) registration, with number of places Banstead Road South (21) DS0000007211.V332987.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow three specified service users over the age of 65 years to be accommodated A variation has been granted to allow three specified service users over the age of 65 years to be accommodated until such time that the home is no longer able to meet their assessed needs. A variation has been granted to allow one specified service user with a physical disability to be accommodated A variation has been granted to allow one specified service user with a physical disability to be accommodated until such time that the home is no longer able to meet their assessed needs. 2. Date of last inspection Brief Description of the Service: 21Banstead Road South is registered with the Commission for Social Care Inspection to provide residential care for up to seven adults with learning disabilities and hearing impairments. The home is owned, managed and staffed by the Surrey and Borders NHS Trust, a specialist health provider for people with learning disabilities. The home is a large detached house built over two floors comprising of seven single occupancy rooms, a dining room, a lounge, a kitchen laundry and quite room. 21 Banstead Road South is situated on a residential road in Sutton. It is close to local shops and transport links. The home also has a large garden equipped with garden furniture. The home also has its own minibus which is used to access other community facilities and day care. Banstead Road South (21) DS0000007211.V332987.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced site visit was carried out between 1.30pm and 4.30pm on a Monday afternoon. The last inspection took place at the home on the 23rd November 2005. The manager currently registered with the Commission For Social Care Inspection to run the home has been working in other services within the Surrey and Borders NHS Trust since July 2006. During this period the deputy manager, Lesley Simpson, has been in day-to-day charge of the home. Methods of inspection included a tour of the premises, observation of contact between staff and service users and discussion with service users, members of staff on shift and Ms Simpson. Records examined included service users plans, care plans, risk assessments, complaints, adult protection, staffing records, Criminal Records Bureau Checks, medication, and health and safety records. Requirements set at the last inspection have been met. What the service does well: Overall the home continues to provide a good standard of care to the people living there. The staff team have a range of skills and abilities including knowledge of sign language, which enables them to communicate with, and meet the needs of, the service users. Any new staff recruited to the home must have signing skills or be prepared to learn. The service users physical and emotional health needs is well maintained. The home is very much geared to meeting the specific needs of the service users. The Royal Association for the Deaf (RAD) plays a key role in the home in supporting/developing/promoting communication between the service users and the staff team. It is evident that service users have been and continue to be supported in completing their own person centred plans. Service users have comprehensive individual care plans with detailed information on their needs and personal goals. Service users are encouraged to maintain and develop independent living skills and there is a strong emphasis on using the community facilities. Service users are encouraged to participate in the day-to-day operation of the home and to give their opinion about the way the service is delivered. Banstead Road South (21) DS0000007211.V332987.R01.S.doc Version 5.2 Page 6 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. Banstead Road South (21) DS0000007211.V332987.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 Banstead Road South (21) DS0000007211.V332987.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, 3, 4 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information included in the homes Statement of Purpose is out of date and misleading. This could result in any new service users not receiving the service they expected when they first moved to the home. EVIDENCE: Banstead Road South (21) DS0000007211.V332987.R01.S.doc Version 5.2 Page 9 Ms. Simpson stated that the manager currently registered with the Commission to run the home left to work in another Surrey and Borders NHS Trust home in July 2006. She was not certain if or when he would return to manage the home. Since the registered manager moved Ms. Simpson has been in day-to-day charge of the home. In July 2006 she informed the commission that she would be in temporary charge of the home but at that time didn’t think that she would still be running the home almost nine months later. Ms. Simpson stated that the Statement of Purpose was updated in October 2006 however the document still includes the registered managers details and infers that he is running the home. The homes Statement of Purpose must be updated to accurately reflect the current management arrangements at the home. The home is registered with the Commission for Social Care Inspection to provide residential care for up to seven adults with learning disabilities and hearing impairments. A service users guide has been developed in Widget symbol and picture format for the easy understanding of the service users. No new service user has moved to the home since the last inspection. The home has a procedure for introducing service users to a new residential placement, which includes the homes, own assessment process and introductory visits. Service users are only admitted to the home once a full assessment of their needs; compiled by their care manager or other relevant person has been received. The Royal Association for the Deaf works along side the service users and the home in an advocacy capacity and is always involved in the assessment process for any prospective service user who wishes to move into the home. Each of the service users has a personal contract, specifying the terms and conditions of their occupancy that includes periods of notice, fees charged, and the cost of ‘extras’ not covered by the basic cost of the placement. Banstead Road South (21) DS0000007211.V332987.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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is evident that service users have been and continue to be supported in completing their own person centred plans. All of the service users have comprehensive individual care plans with detailed information on their needs and personal goals. Service users have risk assessments and risk management strategies in place so that they can participate in activities in the home and in the community in a safe manner. EVIDENCE: Two service users files were examined. One service user had an essential lifestyle plan and a health action plan. The essential lifestyle plan had last been reviewed in May 2005. Banstead Road South (21) DS0000007211.V332987.R01.S.doc Version 5.2 Page 11 The service user had an annual care review in October 2006; this was attended by the service user, his sister, a day service key worker, the service users care manager, a representative from The Royal Association for the Deaf, a support worker and the deputy manager. This was a review of his assessed needs; subsequently achievable goals were set and an action plan put in place. The other service user had a person centred plan and a health action plan these had been reviewed in February 2007. Both service users had a needs assessment from their placing authority on file. Ms. Simpson stated that all of the service users person centred plans/essential lifestyle plans were currently under review using a document developed partially by the Surrey and Borders NHS Trust “how person centred are peoples plans” as guidance to ensure that the plan belonged to the service user. It is recommended that the deputy manager contact Croydon Councils Person Centred Planning team for further assistance in developing the Person Centred Plan approach. As part of a wider discussion on person centred planning it was recommended that the person centred plans include a section on the diverse needs of the service users. It was noted that some service users had completed life maps. Ms. Simpson produced a life map for one service user that he had completed some time ago but he chooses not to use it or update it at the present time. The Royal Association for the Deaf provides support to the service users at their review meetings. This entails meeting with the service user before the review to make sure they are happy and supporting them at the actual meeting. The home has a folder that holds all of the service users risk assessments. One risk assessment sampled had last been reviewed in 2005 however the majority of the risk assessments had recently been reviewed and updated. Ms. Simpson stated that all of the risk assessments are being reviewed at present. The home is having its roof replaced, it was noted that a risk assessment has been set in place for this and a risk assessment has recently been developed for service users opening the front door to strangers. Banstead Road South (21) DS0000007211.V332987.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to maintain and develop independent living skills and there is a strong emphasis on using the community facilities. Dietary needs are catered for with meals that are nutritionally well balanced, nicely presented, and clearly based on the service users food and drink preferences, providing them with daily variation and healthy eating options. EVIDENCE: Service users are encouraged to maintain and develop independent living skills and there is a strong emphasis on using the community facilities. Service users attend a variety of daytime activities. Most of the service users attend the Bentley Day Centre during the week; some service users attend adult education classes’ for cookery, arts and crafts and computer studies. Banstead Road South (21) DS0000007211.V332987.R01.S.doc Version 5.2 Page 13 Some service users attend the Westcroft leisure centre on Wednesdays. Two service users attend work action and are able to earn some extra money. One service user goes on walking trips with Mencap on Thursdays. Service users go to cinemas, restaurants, bowling and shopping in the local community. The home has its own minibus which is used to access other community facilities and day care. The Royal Association for the Deaf works along side the service users and the home in an advocacy/support capacity. On Thursday’s service users hold a community group and an advocacy group on alternate weeks. Relatives are encouraged to keep in contact and visit the service users. Some of the service users do not have relatives however all have a relative, an advocate from The Royal Association for the Deaf or a befriender. The menus at the home are based on the likes and dislikes of the service users and are in a picture/symbol format. Some service users assist with meal preparations. The staff team at the home translate the recipes from the cookery evening class into symbol format for the service users. The home was awarded a healthy eating award from the London Borough of Sutton in 2005. Many of the service users have lived at the home since it opened. Service users spoken to during the inspection said that they were very happy living at the home. Banstead Road South (21) DS0000007211.V332987.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. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users physical and emotional health needs is well maintained. The home is very much geared to meeting the specific needs of the service users. The Royal Association for the Deaf plays a key role in the home in supporting/developing/promoting communication between the service users and the staff team. The homes policies and procedures for handling medicines in the home ensure the service users are so far as reasonably practicable protected from harm and/or abuse. EVIDENCE: The home is registered with the Commission for Social Care Inspection to provide residential care for up to seven adults with learning disabilities and hearing impairments. It is very evident that the home is geared to meeting this specific need. Banstead Road South (21) DS0000007211.V332987.R01.S.doc Version 5.2 Page 15 The staff team at the home have a range of skills and abilities including a knowledge of sign language, which enables them to communicate with, and meet the needs of, the service users living at the home. Any new staff recruited to the home must have signing skills or be prepared to learn. All of the service users are able to communicate in Makaton or British Sign Language or have their own version of communication. Staff were observed communicating with service users using the service users preferred method of communication. The Royal Association for the Deaf plays a key role in the home in supporting/developing/promoting communication between the service users and the staff team. Medication is stored in a locked cabinet in the office. Medication records were checked and were up to date and accurate on the day of the inspection. As required at the last inspection all medication records appear to be correctly filled in at all times. All service users are registered with a local General Practitioner. All service users have a health action plan. The health action plan includes a record of health care appointments attended by the service user. One service user uses a wheelchair so ramps and slopes are in place both inside and outside of the home to aid her mobility and access needs. The level of personal care a service user needs is detailed at their person centred plan/essential lifestyle plan. Personal care is provided in private, and timings of this are also flexible. Banstead Road South (21) DS0000007211.V332987.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is complaints policy and procedure, which facilitates good access to the complaints system for service users, their family or their representatives. The home has suitable vulnerable adult protection and abuse prevention measures in place to ensure the service users are so far as reasonable practicable protected from abuse, neglect and/or harm. EVIDENCE: Ms Simpson stated that there had been no complaints made to the home since the last inspection. The homes record of complaints book confirmed this. The complaints procedure is clear and contains all of the elements required to meet standard 22 including a minimum response time of less than 28 days. The complaints procedure is also in Widget symbol and picture format. The home has a copy of the local authority Adult Protection Policy on site. The Surrey Borders Partnership Trust provides mandatory Vulnerable Adults training for staff. Staff training records indicated that all members of staff had attended adult protection training in 2006. Banstead Road South (21) DS0000007211.V332987.R01.S.doc Version 5.2 Page 17 Banstead Road South (21) DS0000007211.V332987.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, 25, 26, 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home provides a comfortable, clean and safe environment for service users to live in. The general décor of the home is of a good standard. EVIDENCE: The home is situated on a suburban street in Sutton reasonably close to local shops and facilities. The home was comfortable, bright, well ventilated and free from offensive odours on the day of the inspection. The home’s premises are in keeping with the local community and appear suitable for their purpose. Banstead Road South (21) DS0000007211.V332987.R01.S.doc Version 5.2 Page 19 The communal facilities include a well-furnished lounge, dining room, kitchen and a smoking/quiet room. There is a fish tank in the dining room. The home has two bathrooms; one has a parker bath, and a shower room. The overall condition and décor of the home was good. The service users bedrooms have been furnished and decorated to reflect their individual tastes and personalities. As previously stated one service user uses a wheelchair so ramps and slopes are in place to aid her mobility and access needs. As required at the last inspection carpets have been replaced in the lounge and the ground floor hallway. Banstead Road South (21) DS0000007211.V332987.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team at the home have a range of skills and abilities including a knowledge of sign language, which enables them to communicate with, and meet the needs of, the service users living at the home. EVIDENCE: The current staffing establishment for the home is one deputy manager and five support workers. Ms. Simpson has completed NVQ levels 2 and 3 and is working towards completing level 4. Three members of staff have completed NVQ level 2. Staff training records indicated that staff has attended training on health and safety, food hygiene, first aid, fire safety, adult protection, moving and handling, medication, equal opportunities and diversity and person centred planning. Ms. Simpson stated that some of the records had not been updated to include further recently attended training. Ms. Simpson produced one member of staffs annual appraisal. The appraisal included a personal development plan that identified the member of staffs Banstead Road South (21) DS0000007211.V332987.R01.S.doc Version 5.2 Page 21 training needs. The plan also indicated how and when the member of staff could access this training. All members of staff have an annual appraisal. One member of staff started work since the last inspection. Ms. Simpson produced a copy of the member of staffs Criminal Records Bureau Check. The Commission had observed Criminal Records Checks for all other staff currently working at the home at previous inspections. Ms. Simpson stated that The Royal Association for the Deaf supports service users in the homes recruitment and selection process. Service users are able to take part in the interviews of prospective staff and have a say on who is employed at the home. As previously stated the staff team at the home have a range of skills and abilities including a knowledge of sign language, which enables them to communicate with, and meet the needs of, the service users living at the home. Any new staff recruited to the home must have signing skills or be prepared to learn. Banstead Road South (21) DS0000007211.V332987.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 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The current status of the manager registered with the Commission to run the home needs to be clarified. The deputy manager appears to have managed the home well in his absence. Service users are encouraged to participate in the day-to-day operation of the home and to give their opinion about the way the service is delivered. EVIDENCE: Banstead Road South (21) DS0000007211.V332987.R01.S.doc Version 5.2 Page 23 As previously stated in this report the manager currently registered with the Commission to run the home left to work in another Surrey and Borders NHS Trust home in July 2006. Ms. Simpson was not certain if or when he would return to manage the home. Since the registered manager moved Ms. Simpson has been in day-to-day charge of the home. In July 2006 she informed the commission that she would be in temporary charge of the home but at that time didn’t think that she would still be running the home almost nine months later. The Surrey and Borders NHS Trust must ensure that a manager is registered with the Commission For Social Care Inspection to run the home. Service users are encouraged to participate in the day-to-day operation of the home and to give their opinion about the way the service is delivered. The Royal Association for the Deaf facilitates service users meetings at the home. They also assist with staff recruitment and selection, service user admissions, service users reviews and any medical appointments. Regulation 26 visits are carried out at the home on a regular monthly basis copies of the reports are sent to the Commission. Ms. Simpson stated that service users, service users relatives, visitors and staff are encouraged to complete questionnaires about the quality of the service provided at the home. She produced a visitor’s survey that also included a request for comments or suggestions for the home to consider. Ms. Simpson produced a Landlords Gas Safety Certificate 26/10/06, Portable Appliance Testing Certificate, 29/09/06, Food Hygiene Environmental Health report April 06. Ms. Simpson stated that Surrey and East Sutton Water Board had checked the homes water system for legionellas on the 06/11/06 and the home was awaiting the certificate. It is recommended that the deputy manager forward the legionella-testing certificate to the Commission upon receipt. Fire records indicated that the homes fire alarm system is checked on a weekly basis. A full fire evacuation was carried out on the evening of the 27/12/06. Ms. Simpson stated that a daytime evacuation would be carried out next week. The homes fire appliances had been checked by the Surrey and Borders NHS Trust Works Department on the 17/11/06. The home has a fire manual that informs staff what to do in the event of a fire at 21 Banstead Road. Banstead Road South (21) DS0000007211.V332987.R01.S.doc Version 5.2 Page 24 Banstead Road South (21) DS0000007211.V332987.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 2 X 3 X X 3 X Banstead Road South (21) DS0000007211.V332987.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 (1) c. Timescale for action The homes Statement of Purpose 30/05/07 must be updated to accurately reflect the management arrangements at the home. The Surrey and Borders NHS 30/06/07 Trust must ensure that a manager is registered with the Commission For Social Care Inspection to run the home. Requirement 2. YA37 8 (1) & (2). 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 YA6 Good Practice Recommendations It is recommended that the deputy manager contact Croydon Councils Person Centred Planning team for further assistance in developing the Person Centred Plan approach. As part of a wider discussion on person centred planning it was recommended that the person centred plans include a section on the diverse needs of the service users. It is recommended that the deputy manager forward the legionella-testing certificate to the Commission upon receipt. DS0000007211.V332987.R01.S.doc Version 5.2 Page 27 2. 3. YA6 YA42 Banstead Road South (21) Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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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