Inspection on 28/06/06 for Beauly Way

This inspection was carried out on 28th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beauly Way 23/10/07

Beauly Way 05/01/06

Beauly Way 17/06/05

Beauly Way 11/01/05

Beauly Way 28/07/04

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 Beauly Way 4 Beauly Way Rise Park Romford RM1 4XD Lead Inspector Ms Rhona Crosse Unannounced Inspection 28th June 2006 09:25 Beauly Way DS0000027835.V301208.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 Beauly Way DS0000027835.V301208.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. Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beauly Way Address 4 Beauly Way Rise Park Romford RM1 4XD 01708 756624 01708 372293 yinka@outlookcare.org.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) Outlook Care Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2006 Brief Description of the Service: Beauly Way is a purpose built home for 6 younger adults (all males) with learning disabilities and offers 24 hour care. Accommodation is on two floors and all bedrooms are single occupancy. There is a secure garden for service users to use. The home is situated in a residential area of Rise Park and is near to local shops. Thee are no parking restrictions in the street outside the home. Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced therefore the home did not know the inspector was coming. The inspector arrived at 09.25 and was at the home for the whole day. The manager was not at the home when the inspector arrived but came to the home later in the morning as he was attending a meeting. The fees for the home are £1145.00. Due to the complex needs of the service users the inspector was only able to speak to one service user. The inspector watched interaction between service users and staff. No relatives were visiting the home at the time of the inspection. However in conversation via telephone relatives contacted stated they were happy with the service the home provides. Records were inspected relating to the care of service users. Staff were spoken to as part of the inspection process. At the last inspection in January 2006 it was observed that the home was experiencing problems. As a result of this a new manager was put in post at the end of May 2006. In under a month the home has changed dramatically. The manager should be congratulated for the hard work that has taken place to improve the standard of management and get the staff working together as a ‘team’. The staff should be congratulated for their hard work in improving the standard of care they are providing. The new manager, although registered to manage another home must now apply for registration for this home. What the service does well: What has improved since the last inspection? There are many areas that have improved since the last inspection. There have been some staff changes and a new deputy manager is now in post. The most notable change is the atmosphere of the home and the rapport between service users and staff. The inspector observed changes in the Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 6 confidence of the service users who were much more relaxed and interacted very well with the inspector at this visit. The Service Users Guide is now in picture format and the Statement of Purpose is currently being reviewed. Each service user has their own individual menu. Pictorial menus are now being used to enable more choice. More fresh food is being used and new meals are being introduced slowly. Some were said to be successful others were not. The service users care plans are being created into picture format by the manager. The manager is using photographs of the home and it’s contents. This relates more to the services users than pictures used form computer graphics of magazines. Reviews are taking place for all service users and health care needs are being monitored well, with referrals as necessary to health care professionals. Medication practice had been poor but this has been addressed with more training for staff and advice given by the CSCI pharmacy inspector has been acted upon. What they could do better: The new manager, although registered to manage another home must now apply to be registered for this home. The new manager must complete a training and development plan for each member of staff. Although there is a programme of redecoration the hallway upstairs requires a repair to the wall outside one bedroom door. The odour of stale urine in the upstairs corridor to the bedrooms on the left hand side of the house remains a problem. Daily shampooing of the carpet is not solving that. This carpet requires replacing with an appropriate carpet designed to deal with continence problems. A quality assurance survey should be carried out later in the year to gage the changes that will have been made by then and whether relatives and health professionals are happy with the service being provided. Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 7 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. Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 The quality in this outcome area is good therefore there are more strengths that weaknesses. The Statement of Purpose is being updated once this is achieved the home will be providing all that is necessary for a new service user to know what it is like to live in the home and the relatives to know the quality of service available. EVIDENCE: The home has a Statement of Purpose and this is being updated at present. Since the last inspection the Service Users Guide has been produced in picture format to enable service user to know what the home is like and the kinds of things that the service users do living in the home. The current 5 service users have been living at the home for some time. There is one vacancy. It is the procedure of the home to ensure that any new service users are appropriately assessed prior to admission. The admission process may take a period of time depending on the needs of the prospective service user. The placing authority will provide an assessment, the home will also carryout it’s own assessment to ensure that the service users needs can be met appropriately. The prospective service user may make several visits to the home and possibly an overnight stay would be arranged to enable the service users already living at the home to see if they accept a new person into their home. As some of the service uses have Autism any change to the normal pattern of daily life can be quite disturbing to them. Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 10 All service users have a written contract and also a contract in picture form. Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 The quality in this outcome area is good therefore there are more strengths that weaknesses. The welfare of service users is being well met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each service user has a person centred care plan. Since the new manager took over he has been working to ensure that the information held in the care plans are provided in picture form and has been taking photographs within the home to provide pictures that service users are familiar with, and have, a greater understanding of what the pictures mean than that using pictures from other sources. This is seen as very good practice. Once this is work completed for all service users the quality outcome area for this standard will be excellent. Since the new manager took over the home service users are now being consulted about what they want and assumptions of what the service users want are no longer made by staff on their behalf. Although the process can be very involved as some service users have no speech. Therefore all changes are fed back to service users by verbal and Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 12 physical prompts. The responses that staff get back is either by body language or known signs from the service users. The lounge furniture was re-arranged by this process. This was to give all service users better viewing access to the television. The manager is looking at introducing communication cards that will be simple pictures to be used in conjunction with speech to enable service users to have a greater understanding of what staff are saying to them. Service users are encouraged to help in the home, they may be able to bring their laundry down to the laundry room or make a cup of tea, or assist in the kitchen with some food preparation. Staff were observed throughout the day to ask service users what they wanted and time was given for the service users to indicate their needs. Two service users wanted to go out and were taken in the homes transport to Southend for lunch out. They returned later in the day and one of the service users who has speech told the inspector ‘ I like going to Southend and I had chips and peas and fish to eat.’ ‘We saw the sea and went for a walk’ was another comment made. Service users are encouraged to take reasonable risks. Risk assessment were observed to be updated and one was risk assessment was recently changed due to the needs of the service user. A review is to be held for another service user who is deemed at risk in an upstairs bedroom and a change to a ground floor bedroom would be more beneficial. This will be discussed with the relatives, health care professionals and anyone involved in the care of the service user before a decision is made. Restriction of service users rights are recorded where it is deemed necessary. With good ‘Positive Response’ the need for any restrictions should decrease. Due to the complex needs of service users they would not have any understanding of standard 10. Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 The quality in this outcome area is good therefore there are more strengths that weaknesses. The home promotes choice for each individual in all aspects of daily life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current service users use the facilities in the local community. They are supported to go to the GP surgery and to visit other health professionals. Although some do make home visits if necessary. One service user’s weight is being monitored and a food supplement is being provided. Trips to local shops and supermarkets are made with the support of staff. One service user attends a day centre and was not the home at the time of the inspection. The other service users needs are such that none go out to educational projects or supported work projects. Activities are being increased. A trip to Southend took place on the morning of the inspection and two service users went with staff and they had lunch in Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 14 Southend. More day trips out are to be organised and it was said that at least once a month a trip out would be taking place. A Barbecue took place 2 weeks ago and it was said that all the service users enjoyed this. Aromatherapy is to be used for foot and hand massages, music therapy is also being looked into. One service user wants to join a swimming club and this is also being planned. The annual holiday is not yet planned but service users have been looking at pictures of where they could go to, a choice has yet to be agreed. The holiday will take place later in the year. Although the service users would be unlikely to have any understanding of voting in local/general elections they are placed on the electoral role and a voting card was observed to be held in the file of one service user. Links with family and friends are encouraged and the home supports one service user to meet up with his mother outside of the home. There are no restrictions placed on visiting times to the home. Since the new manager the home is looking at more health eating and more fresh food is being prepared. Fresh fruit was observed in the kitchen for service users to eat. Each service user has an individual menu. New meals are being tried to encourage a wider choice of meals. It was stated that some have been successful whilst others have not and will not be provided again. In this case the service user who did not like the new meal was provided with an alternative as soon as it was established that he did not like the new meal. Pictorial menus are being used to good effect, this was observed at the time of the inspection. There are no set ‘house rules’ and service users were observed to go about the home freely. At the time the inspector arrived one service user was still in bed, as he did not want to get up. One service user locks his bedroom and as he was out of the home the inspector was not able to see his room. Another service user also locks his room but was happy to show his room to the inspector. Service users were observed to be spoken to with respect and names that service users prefer were observed to be used. The responsibility for the cleaning of the home is mainly the housekeeper’s task, however some service users are able to take their laundry down to the laundry room and others will make a cup of tea. In general their abilities are such that only tasks that have been risk assessed are carried out due to their complex needs. Beauly Way DS0000027835.V301208.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 The quality in this outcome area is good therefore there are more strengths that weaknesses. Service users health and welfare is being monitored and records evidenced this. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the service uses require support to deal with personal hygiene. There is a mix of male and female staff within the home so service users have a choice of who provides their personal care. Service uses were observed to be dressed in clothing that was appropriate for the time of year and suited their personalities. In discussion about choice of clothing and the purchase of new clothes, it was stated that some service users are able to indicate what clothes they would like to wear. Others use known body language. The process of elimination of staff holding certain items up for them to choose from is also used. One staff member had shown pictures to a service user of clothing that he thought he might like and was then going to buy new clothes for him. Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 16 There was a relaxed atmosphere in the home with meals and mealtimes being flexible if required (one service user remaining in bed until late morning). Health care needs were well recorded with information easily retrievable. Support is being sought from the speech and language therapist and records evidenced that service users are assisted to access dental care, opticians and the chiropodist. There is also good support from the community nursing team. Concern about a weight loss of one service user has been addressed with referral to the speech and language therapist. A food supplement is being provided and weekly monitoring of his weight as per the therapists instructions is taking place. The service user’s weight has now increased and has remained stable for the last month. Another service user has received tests for diabetes and although not diagnosed as having diabetes does sometimes have tendencies to lapse into a similar state to hypoglycaemia. Specific guidelines have been written for staff to deal with this problem. None of the service users are able to self medicate therefore all the medication they require is administered by staff. In the past there had been concerns about the medication practice. The home was visited by the CSCI pharmacy inspector and advice given has been acted upon. New medication cupboards have been provided. The home is changing the pharmacy that provides the medication to a pharmacy that will offer more support. This is to take place when the next month’s medication packs are delivered. The staff have all received updates of medication training. This is identified in the medication folder along with the staff’s signatures. Medication practice was seen to be appropriate at the time of this inspection. Medication administration sheets were appropriately signed. Information on the medication administration sheets corresponded with the medication held in the home. Beauly Way DS0000027835.V301208.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The quality in this outcome area is good therefore there are more strengths that weaknesses. Service uses are protected by the policies and procedures in place and the monitoring systems of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been one complaint made. A record was made of this and the action taken to deal with the situation. The complaint did not relate to the care of the service users. A meeting has been held with the complainant to review the situation that arose and a way forward has been agreed that appears to be working well. Although service users are unlikely to be able to make a complaint their relatives or outside agencies that are used would do this on their behalf should and concerns be noted. The service users do have an advocate who is working with them on a monthly basis and he would also raise any concerns should the need arise. The home has a policy and procedure for dealing with complaints and the CSCI contact number and address is available. Not all staff have attended training in the protection of vulnerable adults but the manager has spoken about this to staff outlining the process. The home is waiting for the dates to be confirmed when this training is to be provided. Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 18 Service users money held in safekeeping was inspected. Money held corresponded with expenditure. However 2 vouchers had been counted along with the cash held for one service user. Vouchers are not ‘cash’ and should therefore be recorded separately from the cash held. The document was amended in the presence of the inspector. Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 & 30 Standard 29 does not apply to this home. The quality in this outcome area is good therefore there are more strengths that weaknesses. The home has a programme of refurbishment. Areas that require attention are being addressed by the manager. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was clean and tidy. The lounge has had new furniture, curtains and carpet fitted. The kitchen/dining room was clean and bright. The manager stated that the bedrooms were to be decorated and that service users were to pick new colours for the walls. Bedrooms were very individual with some having lots of personal possessions and other choosing to have the minimum of things displayed. 2 service users choose to lock their bedroom doors. All bedrooms are fitted with suitable locks that offer privacy but can be opened in an emergency from the outside. In the hallway the wall outside one of the bedrooms has several cracks that require repairing and then decorating after this work has been completed. The bathrooms were clean and free from odours. The laundry room was clean. Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 20 The hallway leading to the upstairs W.C. from the bedrooms on the left hand side of the house had an odour of stale urine. The carpet in the hallway is shampooed on a daily basis but the odour of urine cannot be removed. The carpet requires replacing and the manager is looking into a suitable replacement carpet for this area. None of the service users need equipment, aids or adaptations for physical disabilities although one bathroom has a ceiling hoist and there is a ceiling hoist in one bedroom, neither of these is used. The gardens to the front and the back of the home are well maintained. There is a summerhouse in the rear garden and a swing that is enjoyed by one service user. The garden is secure enabling service users to wander at will in the safety of the garden. Parking is to the side of the home and there is also parking in the street outside the home. Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 The quality in this outcome area is good therefore there are more strength than weaknesses. The manager is ensuring that the staff have the skills to meet the needs of the service users by ensuring that they are appropriately trained. This enhances the care being provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff spoken to as part of the inspection showed a good knowledge of the service users and their needs. Although the manager was not at the home when the inspector arrived the staff were going about their duties in a professional manner and the home had a good atmosphere and was well organised. The new manager held a staff meeting on the 23/6/06 and spoke about his aims and objectives for the home in relation to the company policies and procedures. A further staff meeting took place on the 26/5/06 where other issues were raised. Minutes are kept of these meeting and these are available for staff if they are unable to attend. The manager has been looking at staff files to identify the training undertaken and the training still required. At present staff do not have individual training and development plans, the manager will be drawing these up. However the Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 22 manager is looking at providing refresher courses in Autism and Epilepsy. Diabetes training is also to feature due to one service user’s needs changing. Staff files were inspected (4 of the most recently recruited staff). All held the appropriate information required by legislation all had CRB disclosures returned. Staff files held copies of their terms and conditions of employment. Training certificates were also held on file. Training that they had undertaken this year by staff was: Positive Response, food hygiene, basic first aid, medication training and health & safety training. All had received training in the company’s induction training on policies and procedures. The homes induction programme had also been undertaken for the 4 staff checked as part of the inspection process. The manager has commenced formal supervision sessions with staff and in the month he has been at the home he has carried out 3 supervision sessions on the 24/5/06, 4/6/06 and the 13/6/06. A supervision chart is kept and this identifies when supervision has taken place. This is seen as good practice. Appraisals of staff performance are also undertaken as part of the procedures of the company. Some care staff have NVQ qualifications. 2 staff files inspected held NVQ level 3 and level 2 qualifications. The home is aware that 50 of the staff team must be trained to NVQ level 2. Due to the service users exhibiting challenging behaviour training in dealing with this is being provided. The manager who is a qualified ‘Positive Response’ trainer is training the staff in the use of these techniques. In the month that the manager has been at the home there have been two training days and three staff have been trained to use this technique for defusing situations before they escalate. Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 The quality in this outcome area is good therefore there are more strengths that weaknesses. The service uses are benefiting from the way the home is managed. The record keeping and the policies and procedures of the home safeguard their rights and best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is being run for the benefit of the service users. This is clear from the way service users are encouraged (despite their lack of speech in some cases) to show their choice in the refurbishment of the home by picking colours and in the choices offered to them in their daily life. The home has a quality assurance system in place. The new manager should implement this when he has been at the home for a longer period of time to enable relatives to get to know him and also allow time for further changes to take place. Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 24 All health and safety records were in order as identified in the Regulation 26 visit report for June 2006. Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 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 2 25 3 26 3 27 3 28 3 29 N/A 30 2 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 N/A LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 x 2 x x 3 x Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 26 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. 1 Standard YA1 Regulation 4 Requirement Timescale for action 30/07/06 2 3 YA24 YA24 4 5 6 7 YA32 YA35 YA37 YA39 Complete the review of the Statement of Purpose and make available to any new prospective service users. 16(2)(k) Replace the carpet in the hallway (due to the odour of urine that cannot be removed). 23(2)(b) Repair the cracks in the hallway outside the bedroom door identified to the manager and decorate the walls. 18(1)(c)(i) The manager must ensure that 50 of the staff team are trained to NVQ level 2. 18(1)(c)(i) The manager must ensure that all staff have a training and development plan. 9 The manager must apply for registration with the Commission. 24(1)(a) & Carryout a quality assurance (b) survey. The analysis of the findings should form part of the service users guide. 30/07/06 30/08/06 30/06/07 30/09/06 30/07/06 30/10/06 Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA34 Good Practice Recommendations Gift vouchers must not be recorded as cash. These must be recorded separately identifying the amount they are worth. Beauly Way DS0000027835.V301208.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 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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