Inspection on 27/11/07 for Banstead Road South (21)

This inspection was carried out on 27th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Banstead Road South (21) 19/03/07

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

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Ashlong House

Norbury Crescent (30)

Edenvale

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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 27th November 2007 10:00 Banstead Road South (21) DS0000007211.V355187.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.V355187.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.V355187.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 8643 8275 max.edward@sabp.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.V355187.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. 19th March 2007 2. Date of last inspection Brief Description of the Service: 21 Banstead 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.V355187.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 9.30am and 12.30pm on a Tuesday morning/afternoon. This inspection also involved a visit by an expert by experience who spent time talking with some of the people who live here and members of staff. Methods of inspection included a tour of the premises, observation of contact between staff and residents and discussion with residents, members of staff on shift and the registered manager. 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. What the service does well: What has improved since the last inspection? Banstead Road South (21) DS0000007211.V355187.R01.S.doc Version 5.2 Page 6 As required at the last key inspection Surrey and Borders NHS Trust has registered a manager with the Commission to run the home. The homes Statement of Purpose has been updated. The home is developing the Person Centred Plan approach. 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.V355187.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.V355187.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 and 2. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. People considering using the service are provided with all the information they need to make an informed decision about whether or not the home is capable of meeting their needs however this information needs to be updated. EVIDENCE: As required at the last key inspection the homes Statement of Purpose has been updated. The expert by experience observed that there was an information book with the staff’s details for residents to look at and a resident’s book. This was the service users guide, it is available in Widget symbol and picture format for the easy understanding of some the residents. 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. The Royal Association for the Deaf works along side residents and the home in an advocacy capacity and is always involved in the assessment process for any person who wishes to move into the home. Banstead Road South (21) DS0000007211.V355187.R01.S.doc Version 5.2 Page 9 The Commission has revised its procedures for setting categories as conditions in keeping with the principles of Inspecting for Better Lives. It is no longer required that providers should seek a variation to support adults over the age of 65. The conditions to allow people over the age of 65 and one person with a physical disability to live at the home will be removed and a new certificate will be sent to the home. No new people have moved to the home since the last inspection. The home has a procedure for introducing people to a new residential placement, which includes the homes, own assessment process and introductory visits. People 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. Banstead Road South (21) DS0000007211.V355187.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, 8 and 9. Quality in this outcome area is excellent. This judgement has been made using all the available evidence including a site visit to this service. It is evident that the home is run on a person centred approach. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. People 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: The Royal Association for the Deaf (RAD) plays a key role in the home in supporting/developing/promoting communication between people living at the home and the staff team. The RAD provides support people at their review meetings. This entails meeting with people before the review to make sure they are happy and supporting them at the actual meeting. Banstead Road South (21) DS0000007211.V355187.R01.S.doc Version 5.2 Page 11 The RAD also works along side residents in an advocacy/support capacity. On Thursday’s people hold a communication group and an advocacy group on alternate weeks. The staff team have a range of skills and abilities including a knowledge of sign language, which enables them to communicate with, and meet the residents needs. Any new staff recruited to the home must have signing skills or be prepared to learn. All of the residents are able to communicate in Makaton or British Sign Language or have their own version of communication. Staff were observed communicating with people using the persons preferred method of communication. It was reported at the last key inspection that people had annual reviews, these were attended by the person, their family, a day service key worker, the persons care manager, a representative from the RAD and a manager from the home. The review assessed individual needs; subsequently achievable goals were set and an action plan put in place. It was recommended that the home contact Croydon Councils Person Centred Planning team for assistance in developing Person Centred Plans. A Croydon Council Person Centred Planning co-ordinator visited the home and offered some advice on Person Centred Planning. Residents had completed their PCP’s in widget, words and pictures and included a section on diversity. The registered manager told us that he has sought advice on the issue of diverse needs and is currently searching for good working practices on the CSCI website and other social care publications. Two peoples files were examined. Both files included person centred plans, health action plans and risk assessments. The registered manager told us that four of the six people living at the home had their placements reviewed by their care manager and the two remaining people was due to have a review in December. Peoples risk assessment sampled had been reviewed on a regular basis. Banstead Road South (21) DS0000007211.V355187.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. Residents can be assured that the home will support them to improve and develop their communication and encourage independent living skills. EVIDENCE: People are encouraged to maintain and develop independent living skills and there is a strong emphasis on using the community facilities. People attend a variety of daytime activities. Most attend the Bentley Day Centre during the week; some attend adult education classes’ for cookery, arts and crafts and computer studies. Some attend the Westcroft leisure centre on Wednesdays. Two people attend work action and are able to earn some extra money. People are supported to go to cinemas, restaurants, bowling and shopping in the local community. The registered manager told the expert by experience that residents could choose to go to church, there is a signing service once a month. The home has Banstead Road South (21) DS0000007211.V355187.R01.S.doc Version 5.2 Page 13 its own minibus which is used to access other community facilities and day care. One resident told us that he is a member of Advocacy Rocks a group that visits other services to meet and support residents. Relatives are encouraged to keep in contact and visit. Some people do not have relatives however they have an advocate from the RAD or a befriender. The menus at the home are based on peoples likes and dislikes and are in a picture/symbol format. The expert by experience observed that staffs were giving residents a choice of diet. Residents are able to choose what they want to eat. Food is purchased on a Thursday with key workers. Staff told the expert by experience that residents can help with cooking if they want but most residents choose not to. There was fresh fruit in bowls placed around the home for residents to help themselves. The home had a picture menu on the wall so all residents are able to choose what they want to eat. The home was awarded a healthy eating award from the London Borough of Sutton in 2005. A number of questionnaires were returned to the Commission as feedback from relatives. One relative commented “they make my son very happy in a caring environment” and “the staff is very caring and the key worker is superb”. Another relative commented that “they are giving the residents the care and protection they require so they are living a life that is fulfilled which they may never have received elsewhere”. Residents feedback included comments such as “If something goes wrong I will ask staff for help” and “ I like the staff”. Residents told the expert by experience that they have their own money and can buy want they want. One person said that he washes all the resident’s clothes but he didn’t get paid for it. The same resident saved his money and bought a big TV for his room. The expert by experience said the resident told her he likes sports and can watch/hear this on the TV. The expert by experience observed an activity planner on the wall in picture format. Residents told her that they liked the home and staff were friendly towards the residents during the visit. Staff told the expert by experience that the residents where no longer growing vegetables as they were to old now. There were no animals as residents have not asked, residents have visitors with cats and dogs. One person showed us his battery operated hearing aid. Staff said the residents could choose if they want digital hearing aids – the expert by experience suggested that this person could try out a digital hearing aid. Banstead Road South (21) DS0000007211.V355187.R01.S.doc Version 5.2 Page 14 Banstead Road South (21) DS0000007211.V355187.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents can be assured that their physical and emotional health needs are well maintained because the home is very much geared to meeting their specific needs. Residents can be assured that they will receive personal support in the way they prefer. 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. All of the residents are able to communicate in Makaton or British Sign Language or have their own version of communication. The staff team have a knowledge of sign language, which enables them to communicate with, and meet the residents needs. Banstead Road South (21) DS0000007211.V355187.R01.S.doc Version 5.2 Page 16 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. All of the people living at the home are registered with a local General Practitioner, all have a health action plan, the health action plan includes a record of health care appointments attended. One person 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 person needs is detailed in their person centred plan. Personal care is provided in private, and timings of this are also flexible. Residents told the expert by experience that are able to have a bath when they wish and were able to choose what they wanted to wear. The registered manager said that residents are given keys to their bedrooms so that they can have some time alone if they want. The expert by experience observed there was lots of Makaton sign language being used by staff and residents. Residents told the expert by experience that they can go to the doctors with the carers when they choose to and when they are not well the doctor is called in to the home. The residents all share the same dentist and attend every six months. Banstead Road South (21) DS0000007211.V355187.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. The residents can be assured that the homes procedures for complaints and protection from abuse are well managed and ensure that they are listened to and safe. EVIDENCE: The registered manager told us that there had been no complaints made to the home since the last inspection. The expert by experience observed that there was a brochure on abuse and how to tell someone if they do not like this, the brochure was in picture format. 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 located in the hallway and in peoples person centred plans also in Widget symbol and picture format. The complaints procedure indicates that people can tell their key worker, the manager, friend or people at the Royal Association for the Deaf or write to the Commission if they have a complaint. It is recommended that telephone numbers are included on the home’s Complaints Procedure. The home has a copy of the local authority Adult Protection Policy on site. Staff training records indicated that all members of staff had attended adult protection training. Banstead Road South (21) DS0000007211.V355187.R01.S.doc Version 5.2 Page 18 Banstead Road South (21) DS0000007211.V355187.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is excellent. This judgement has been made using all the available evidence during the visit to this service. The home is homely, comfortable clean and hygienic. The residents’ quality of life is being made better by the environment they are living in, the homes décor and furniture is suitable an appropriate to their needs. 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.V355187.R01.S.doc Version 5.2 Page 20 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. One person showed us his bedroom, he was very happy with his 32” flat screen television, he told us that he loved watching sports such as horse racing, football and wrestling. The overall condition and décor of the home was good however the bordering in the downstairs hallway and the décor in the dining room appeared to be rather ‘shabby’ in places. Peoples bedrooms have been furnished and decorated to reflect their individual tastes and personalities. A number of aids adaptations have been made in the home so that it can meet the needs of people with hearing impairments, these include a loop system in the living room and flashing lights in the bedrooms, a blue flashing light signifies that someone wants to enter the room and a red flashing light signifies fire. The home also has a call bell system. As previously stated one person uses a wheelchair so ramps and slopes and a hand rails are in place to aid her mobility and access needs. A number of aids and adaptations have also been installed in the toilets and bathrooms. The registered manager showed us the newly installed range cooker. Residents are keen on recycling the homes waste, there are separate bins for glass and plastic and there is a compost heap in the garden. The expert by experience pointed out that there were no pictures on doors showing residents what was behind the doors. She felt that this would help some people living at the home. Some residents are unable to use the garden on their own without a care worker because the path surface is unsafe. However the registered manager said that people needed a care worker to help them outside and they would make sure they were safe. The expert by experience said that residents rooms have lots of personal items. Residents could choose the colour of their room. The expert by experience said that residents could have a bigger television in the lounge as the one in there was not big enough should all residents wish to watch the television together. The registered manager told us that they had ordered and were expecting a new bigger television to be delivered before Christmas. The expert by experience observed that there were a number of loose wires around the back of the television and pointed out that this could be a hazard. Banstead Road South (21) DS0000007211.V355187.R01.S.doc Version 5.2 Page 21 The expert by experience observed that there was a smoking room available for the residents who choose to smoke, there was two settee’s and a telly for residents to use. The expert by experience said that the home was clean and staff seemed very nice, helpful and they answered all her questions. Banstead Road South (21) DS0000007211.V355187.R01.S.doc Version 5.2 Page 22 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 excellent. This judgement has been made using available evidence including a visit to this service. The staff team are being supervised and trained and have a range of skills and abilities including a knowledge of sign language and that enables them to communicate with the residents and meet their needs. EVIDENCE: As previously stated the staff team 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 residents. Any new staff recruited to the home must have signing skills or be prepared to learn. Staff training records indicated that in the last year staff has attended training on health and safety, food hygiene, first aid, fire safety, adult protection, moving and handling, medication, British Sign Language and some staff had attended Makaton training. Five members of staff has NVQ level 2 or above. Records show that staff are receiving regular formal supervision, at least six sessions per year however the registered manager has had four sessions. It is Banstead Road South (21) DS0000007211.V355187.R01.S.doc Version 5.2 Page 23 recommended that the registered manager receives at least six formal supervision sessions per year. The registered manager told us that all members of staff are undergoing the Surrey and Borders NHS Trusts appraisal system “Knowledge and Skills Framework”. The “Knowledge and Skills Framework” includes a performance development plan. RAD supports residents in the homes recruitment and selection process. Residents are able to take part in the interviews of prospective staff and have a say on who is employed at the home. A number of questionnaires were returned to the Commission as feedback from staff. Comments included “I get six weekly supervision where I can express myself and discuss any issues, I get support from the registered manager and deputy manager at all times”, “the home uses a variety of communication tools/methods so that individuals are well informed and fully involved in the decision making process” and “there is a good team who are committed to work flexibly to support individuals to lead a fulfilling life in the community”. Other comments included “ improve the environment to meet the changing needs of the residents”, “training department is only offering mandatory training for social care staff at present, it is sometimes very difficult to get into courses as they are booked up quickly” and “it can sometimes be difficult to provide 1-1 care when all residents are at home when there are two members of staff on shift”. The expert by experience said that the staff was seen to be kind to the residents. Banstead Road South (21) DS0000007211.V355187.R01.S.doc Version 5.2 Page 24 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 excellent. This judgement has been made using available evidence including a visit to this service. The residents can be assured that the home is managed in a way that promotes their independence dignity and safety. EVIDENCE: As required at the last key inspection Surrey and Borders NHS Trust has registered a manager with the Commission to run the home. The registered manager indicates in the AQAA that the homes philosophy is to ensure a person centred approach, treat people well, promote involvement, maintain a respectful atmosphere and be open, inclusive & accountable. Banstead Road South (21) DS0000007211.V355187.R01.S.doc Version 5.2 Page 25 People living at the home 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. Regulation 26 visits are carried out at the home on a regular monthly basis copies of the reports were available in the home for inspection. The registered manager told us that the home was due to be audited the following week using assessments developed by the Surrey and Borders Trust following the Cornwall Enquiry. The registered manager produced evidence that residents, relatives, visitors and staff are encouraged to complete questionnaires about the quality of the service provided at the home. He produced a visitor’s survey that also included a request for comments or suggestions for the home to consider. The registered manager produced a Landlords Gas Safety Certificate 09/10/07 and a Portable Appliance Testing Certificate 16/10/07. Fire records indicated that the homes fire alarm system is checked on a weekly basis. All staff had attended fire safety training. The registered manager produced a fire risk assessment for the home that had been carried out by the Surrey and Borders Trust fire officer on the 24/10/07. 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.V355187.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 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 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 4 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 4 X 4 X X 3 X Banstead Road South (21) DS0000007211.V355187.R01.S.doc Version 5.2 Page 27 No. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. 1. 2. 3. Refer to Standard YA22 YA32 YA24 Good Practice Recommendations It is recommended that telephone nmbers are included on the homes complaints procedure. It is recommended that the registered manager recieves at least six formal supervision sessions per year. The home could make sure that the loose wires around the back of the television are made safe. Banstead Road South (21) DS0000007211.V355187.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 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 Banstead Road South (21) DS0000007211.V355187.R01.S.doc Version 5.2 Page 29 - 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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