Inspection on 05/07/06 for Beck Farm House

This inspection was carried out on 5th July 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beck Farm House 01/07/09

Beck Farm House 18/06/09

Beck Farm House 02/07/07

Beck Farm House 02/12/05

Beck Farm House 25/07/05

Beck Farm House 07/12/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Beck Farm House Beck Farm House Beck Lane Barrow upon Humber North Lincs DN19 7AF Lead Inspector Janet Lamb Unannounced Key Inspection 5th July 2006 10:00 DS0000060660.V304322.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 DS0000060660.V304322.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. DS0000060660.V304322.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beck Farm House Address Beck Farm House Beck Lane Barrow upon Humber North Lincs DN19 7AF 01469 532988 NOT KNOWN YET beckfarm@tiscali.co.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) Voyage Ltd inc. Thelma Turner Homes Ms Sandie Walker Boyall (unregistered) Care Home 7 Category(ies) of Learning disability (7) registration, with number of places DS0000060660.V304322.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION 1. Beck Farm House is to be registered for 7 young adults with a learning disability between the ages of 16-25 only. The home can accommodate service users aged 16-17 years of age, conditional on there being no service users over the age of 25 years of age at the home. (Supplementary standards for care homes accommodating young people aged 16 and 17 will apply). 02/12/05 unannounced Date of last inspection Brief Description of the Service: Beck Farm House, registered August 2004, is a detached property in Barrowon-Humber, providing care and accommodation on two floors, to 7 adults with learning disability. Young adults with very complex needs and particular disabilities with challenging behaviour are placed in the home as stated in the homes statement of purpose and as a result programmes of care and behaviour management are very defined and strongly adhered to. All rooms are single with en-suite facilities. There are sufficient and suitable communal areas and an enclosed garden. Shops and services in Barton are accessed by car daily and service users often walk to Barton as part of their exercise plan. The minimum and maximum charges made by the service are £1,276.96 and £3,613.77 per week. DS0000060660.V304322.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began with the sending of a pre-inspection questionnaire to the home in May 2006, requesting information on the service provided and the names of those service users living there, as well as the names and addresses of their relatives and any health care professionals involved in their care. Survey comment cards were then issued to as many of these people as possible, including service users, to obtain their views and opinions of the care provided within the service. Then on the 5th July 2006 Janet Lamb and Hilary Slights visited Beck Farm, without prior warning and as part of this inspection. All of the service users were spoken to, but were mostly observed throughout the inspection. The manager and one senior staff member were interviewed. Other staff were spoken to, to obtain particular pieces of information. The main parts of the house were inspected, as was one service user’s bedroom. Care plans, risk assessment documents and some records were read and staff files and training records were seen. All personal and private areas and documents were only seen with the permission of the people they belonged to. Janet and Hilary had lunch in the dining room with two service users and the manager. A short time in the afternoon was spent admiring the newly bought and put up gazebo, and watching the service users enjoying it. What the service does well: Service users know their aspirations and needs are well assessed and recorded in a plan of care, although they are not always fully aware of the implications of such documentation. Service users are encouraged to make decisions for themselves, wherever possible, and to take risks, but only when the risks have been lessened. They enjoy a variety of activities and pastimes and have good relationships with their family members and friends. Service users do not always relate well to each other though, but staff encourage them to be considerate. Service users enjoy meals of their liking and choice and sometimes help to prepare them. One service user said “I like helping Linda in the kitchen.” They are given good support with personal care, keeping healthy and being happy. All service users’ medication needs are safely met. Service users have their complaints and comments dealt with satisfactorily. DS0000060660.V304322.R01.S.doc Version 5.2 Page 6 They enjoy a homely, safe and clean house and one service user, on showing the Inspectors their room, said, “I have a very nice room. Do you like my bears?”. Service users are cared for by staff that are well recruited and adequately trained. They benefit from a home that is well run by a competent manager that ensures the home is a healthy and safe place to live. 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. DS0000060660.V304322.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 DS0000060660.V304322.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 only. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Written assessments are satisfactory and staff hold good knowledge about service users’ daily, diverse needs, making it possible to set good care plans to meet service users’ needs. EVIDENCE: Permission was given by three service users to view their case files, which revealed there are assessment documents completed by the placing local authorities, showing the assessed diverse needs of individuals. Where possible service users have signed them to show they have been consulted and agree with the assessment. One service user said on his survey comment card, “I didn’t choose to come here but John asked me to.” A contract between the placing authority and the provider was seen for one service user. Interviews held with service users could not be done properly in terms of asking questions and receiving answers, because service users are not fully aware of the implications for the documentation required for their continuing care. Observation of their interaction with staff showed they are able to and do seek inclusion in the consultation process on a daily basis. Service users make decisions daily with information from staff. Two service users spent time putting their cases forward regarding their wishes for the day and the immediate future. One was very determined to make staff listen to his point of view and to make them help him achieve his goal. DS0000060660.V304322.R01.S.doc Version 5.2 Page 9 Discussion with the Manager revealed all service users had an initial assessment of needs done and are now having their care plans reviewed in light of the development they have experienced over the last year. One staff survey comment card also expressed the view that service users had changed in terms of their behavioural needs since being admitted to Beck Farm. DS0000060660.V304322.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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. Evidence mentioned below results in a judgement that on many occasions service users do not exercise their rights to make their own decisions because of the risks of injury to themselves and others or the risk of deterioration in their behaviour. Because of this they do not always achieve the outcome they are seeking. EVIDENCE: Care plans are in use, but are currently being reviewed and revised into a new format. They include information on special programmes for behaviour modification and show the input required from medical and health care professionals. They also show restrictions on choices and on freedom and the reasons why. They show the diversity between individuals in terms of learning disabilities and they try to address these according to how needs should be met. There are no service users with particular different religious or cultural needs, but all do have differing needs in respect of their youth and sexuality. A Voyage North employee has a particular remit to support service users with advice and DS0000060660.V304322.R01.S.doc Version 5.2 Page 11 strategies for meeting these needs. Some service users have signed their care plans in agreement they can be implemented. Service users do have some limitations on their rights to make decisions and to take risks within the home, where this is detrimental to their own development or that of another service user and especially where an injury to anyone would arise. Because both of these are likely there are risk assessments in place to reduce the potential for deterioration or injury. An example of service users not being given the right to make their own decision was highlighted and observed when one staff member made a seating plan before five service users were asked to board the bus to take them on a shopping trip to Scunthorpe. The senior on duty studied the plan and agreed the reason and logic for sitting service users and staff in a particular place. There are often occasions when service users rights are not respected, but only and always for the safety of everyone. This was discussed with the senior and explanations were given as to why certain service users, depending on how they are presenting, cannot be allowed to sit next to others and require the close supervision of a one-to-one staff member. Of the eight health care/professional comments cards received comments were generally positive, with the exception of four stating that communication with the home was poor, two stating care staff did not demonstrate clear understanding of service users’ needs, and one stating they thought any specialist advice given to the home was not incorporated into service users’ care plans. In all of this the service users did not once object to the decisions made for them about bus seating. They did exercise their rights to make decisions later in the day though, when choosing their snacks, what they wanted for lunch, what they were going to do in the afternoon, etc. The strict routines expected to be operating in the home were clearly evident throughout the inspection. Staff must and do maintain a balance between encouraging service users to exercise independence and control over their lives, and supporting to the extent of instructing service users what to do on occasion. DS0000060660.V304322.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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. There is good balancing of respecting service users’ rights and the need to ensure their daily choices are informed ones for their health, safety and welfare, but outcomes for service users are sometimes not to their liking. EVIDENCE: Service users’ activity plans and daily diary notes show they engage in chosen activities and pastimes of their liking and preference. There are no service users in employment at the moment, but all have a busy timetable in respect of activities. One relative comment card stated, “My complaints are usually about personal care, lack of community-based activities, stimulating activities etc. Now that Beck Farm is under new management I hope there will be an overall improvement.” Although comments from this relative indicate dissatisfaction with community activities, the evidence shows that service users go out a lot, don’t necessarily engage in activities with other villagers, but that they are DS0000060660.V304322.R01.S.doc Version 5.2 Page 13 generally quite satisfied with the pastimes they have. Information held in the home concerning a complaint from another relative showed the activity variety and frequency to be satisfactory, but there had been dissatisfaction with the lack of information being sent to him. The complainant was satisfied with the outcome of the complaint dealt with by the manager however, when the home resumed informing him of the proposed activities planned each week and continued sending a copy of the actual activities undertaken by the service user concerned. Care staff commented that the home would greatly benefit from another vehicle, as often service users are reluctant to travel with one another and sometimes prefer to go somewhere and do something different. This was observed on the day of the inspection when one service user clearly indicated he did not want to go in the bus with the others. All service users have some level of family or friend contact and this is fully encouraged by the home. Diary notes show with whom, how and when contact was made. Service users spend periods with family or friends on a regular basis. Service users talked about visiting family and what they like to do at those times. Contact with family and friends and support they offer service users is very good, although family members having returned comment cards made claims that communication between the home staff and themselves could be better. There were no comments from service users about meals and the food provided. They have become accepting of their specialist diets and eat the food prepared for and by them without much criticism. Staff made observations on survey comment cards that there are very few choice options and nothing to meet the dietary needs of anyone that may be a vegetarian. No service user was identified as requiring a vegetarian diet, however. The level of consultation on menu planning and choice options could be improved, and this is being explored in service users’ meetings, as can be seen in minutes. Relatives stated they are very satisfied with the results obtained for weight control amongst the service users though. This is another area where service users are unable to exercise their rights to make decisions, but to allow them to do so could be extremely harmful to their physical wellbeing, and indeed life threatening if prevalent eating disorders were out of control. All restrictions and controls and the reasons why are listed in care plans DS0000060660.V304322.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users enjoy good health, receive good emotional support as necessary and have their medication well controlled, so that their general wellbeing is maintained. EVIDENCE: Service users were observed to be in good physical health. They enjoy plenty of exercise, eat well and are assisted to maintain good personal hygiene. Health checks are done as necessary and some service users are supported with home visits. During the time of the inspection a consultant psychiatrist visited to discuss some recent problems being experienced and to review medication if necessary. Service users’ care plans showed details of physical and emotional health needs and when and where visits to hospitals, GPs, clinics, etc. are made. There are also body-mapping documents in place to record any injuries following self-harm or accident or injury by another service user. There are no service users that control and administer their own medication. Medication administration procedures and practice are satisfactory. Senior DS0000060660.V304322.R01.S.doc Version 5.2 Page 15 trained staff give out medicines and use systems correctly. Medication Administration Record (MAR) sheets inspected and medicine storage arrangements seen revealed staff maintain appropriate safe administration practices and recording. The Nomad Monitored Dosage System is in place for all 7, service users. Two of the three seals required on the cassettes are in place. Extra medicines not compatible with other drugs in the cassettes are held in packets. All MAR sheets seen were completed accurately. Stock checks are maintained and recorded within the home and the supplying pharmacist receives and signs for any drugs returned. All medicines given only as required are recorded on the back of the MAR sheets as well as on the front. Only staff trained to administer medication do so. DS0000060660.V304322.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The judgement on protection has been influenced by the past year’s events, but there are now signs that the quality of protection for service users is improving, meaning they are being better protected than before. EVIDENCE: There is a clear complaint procedure, which service users have used in the past, but not in recent months. One was observed making views known on the day of the inspection and did represent himself very clearly. Staff managed to present an alternative, but this was very limited and did not satisfy the service user. He resolved the problem himself by changing his mind about his request. It seems service users and staff face this kind of challenge every day and usually resolve it with compromise. The final outcome for the service user, on returning from a shopping trip, was very much to his satisfaction. There have been four serious complaints made about the home to the CSCI in the last twelve months. Two of these became vulnerable adult referrals, of which one is still on going. Voyage North have dealt with some issues internally and to the complainants satisfaction, but the company needs to finalise complaints more efficiently and make sure it informs the CSCI of the outcomes, especially of those received through the CSCI. There is a system and procedure in place for protecting service users from harm, self-harm and abuse, and there are behaviour management programmes in place for all service users, but because of the high level of behavioural incidents and restraints within the home these systems are being DS0000060660.V304322.R01.S.doc Version 5.2 Page 17 used weekly. The staff team needs to change the way it deals with behavioural issues. Care plans, behaviour management plans and risk assessments are in place for staff to follow but these are now out of date and are in the process of being updated in new formats. The manager is working her way through these documents. She is also working with the consultant psychiatrist in an effort to discover a better means of helping service users to manage their own behaviour and reduce the need for restraining. Meanwhile staff have been redoing their SCIP (behaviour management) training, but not all have had the refresher yet. Management of behaviour could be better, and perhaps more health care professional specialist support is required. After all behaviour management is the biggest single factor within the home requiring specialist and consistent support from care staff. DS0000060660.V304322.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The house is clean and comfortable, service users are satisfied with their rooms, and they can enjoy the house and garden. EVIDENCE: A tour of the communal areas of the premises revealed the dining room has a problem with cracks above the French doors to the garden, due to severe use of the doors and slamming them, as stated in one staff questionnaire. This has been surveyed and is awaiting repairs, according to the manager. The rest of the house is satisfactory. Only one service user’s room was viewed despite permission being sought from three service users. This room was comfortable, clean and very personalised. The occupying service user said “I like my room very much,” and she invited comments on some of the items and possessions she has. There have been no adverse comments about the property from anyone living at Beck Farm or having cause to visit. All rooms are single occupancy and have en-suite toilet and bath. There is a communal garden, which is being extensively used at the moment, weather being so good. Service users went out to purchase a gazebo and they had it DS0000060660.V304322.R01.S.doc Version 5.2 Page 19 erected before the inspection had finished. There are two lounges, which are also very well used during the day and evenings, according to staff and observations of service users doing so. The home is clean and comfortable, but the manager informed CSCI that service users’ rooms, the dining room and one of the lounges are to be redecorated. Service users have chosen colours and styles and work is to begin shortly. DS0000060660.V304322.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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. Recruitment is good and training opportunities are satisfactory, though there is still room for improvement, giving service users better support. EVIDENCE: There were no new staff on duty to seek permission to view their recruitment files and so files of two longer serving staff were viewed. These contained all of the required documents listed in schedule 2, as well as extra items such as hepatitis B disclaimers, a maternity leave plan, declaration of confidentiality, return to work interviews following sickness, etc. Staff also keep their training certificates and details in their recruitment files. There is a wide range of training undertaken, but details showed that some training has not been updated for a while. Staff survey comment cards revealed opportunities are satisfactory, but could be better. This was the case when looking at files and speaking to staff and the manager. The manager is in the process of identifying training needs and these will be planned for and undertaken in the next 6 to 12 months. Staff have been doing NVQ’s but some people did not complete the course. There are currently 12 staff from 22 with the qualification, giving the required 50 to meet standard 32.6. DS0000060660.V304322.R01.S.doc Version 5.2 Page 21 As was indicated in two staff survey comment cards, there has been some unsettled relationships amongst the group, according to the manager, due to some staff being given positions of team leader over others. The manager made clear that only loyal, willing staff that carefully follow care plans and procedure etc. will be given positions of responsibility. The period of unsettlement has also been as a result of the vulnerable adult investigation, which began last August and finished in April 2006, and the changes in the staff team over the last 12 months. It is expected that with the recruitment of the new manager there will be some new direction and leadership for staff to follow. DS0000060660.V304322.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Although the manager is new she is competent to undertake the role and is making improvements within the home, making life better for the service users. Quality assuring the service is satisfactory, but could be developed further, and safety of service users and staff is good. EVIDENCE: There is a new manager in post and she is doing the NVQ level 4 Registered Manager’s Award, and completes in Oct/Nov 06. She will be submitting an application to become the registered manager within the next 4 weeks, following an agreed probationary period with the CSCI of approximately three months. The manager has been effectively managing the home since the end of April 2006. The quality assurance systems are still tentative and include such as surveying service users and relatives, but there are some new questionnaires waiting to DS0000060660.V304322.R01.S.doc Version 5.2 Page 23 be sent out, and the recent changes in management has meant that surveying opportunities have not been taken up for some time. The home holds an annual service review each autumn, and service users’ meetings are held, with minutes maintained showing opinions stated and preferences made. The reviewing of systems should ensure there is a robust means of acquiring the opinions of service users, relatives, health care professionals, etc. on the quality of care provided, in line with regulation 24, on a regular basis. Staff views as to the conduct of the home, regulation 21, should also be considered and included. It is understood that the home has submitted an ‘annual report’ for the year 2005, which includes information on the quality assurance system. Service users were observed making contributions to the day’s activities and happenings, throughout the course of the inspection. Other relevant people are consulted through such as the complaint procedure, but this only happens when someone actually complains. Therefore more needs to be done in respect of direct consultation of anyone having an involvement in the home. The manager maintains safe systems of working within the home and supervises staff in the following of policies and procedures. The home maintains all of the required maintenance checks on equipment and ensures requirements of other regulatory bodies are met in respect of fire safety and environmental health. Fire safety checks within the home are satisfactory, as are external maintenance checks on the fire safety equipment. Staff and written records confirmed weekly fire checks and monthly drills are held. DS0000060660.V304322.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT 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 3 3 3 X 3 X 3 X X 3 X DS0000060660.V304322.R01.S.doc Version 5.2 Page 25 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 12 and 13 Requirement The Registered provider must continue to improve ways in which s/he protects service users from abuse and self-harm. The Registered Provider must notify CSCI in writing of these steps. (Some improvement has been made since the last inspection.) Timescale for action 30/11/06 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 YA39 Good Practice Recommendations The Registered provider should develop the quality assurance systems to take into consideration the opinions of all stakeholders, including staff as in regulation 21 DS0000060660.V304322.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000060660.V304322.R01.S.doc Version 5.2 Page 27 - 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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