Inspection on 01/10/07 for Boundary House

This inspection was carried out on 1st October 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Boundary House 24/08/09

Boundary House 27/11/06

Boundary House 12/01/06

Boundary House 16/08/05

Boundary House 04/03/05

Boundary House 15/09/04

Boundary House 11/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Boundary House Haveringland Road Felthorpe Norwich Norfolk NR10 4BZ Lead Inspector Lella Hudson Unannounced Inspection 1st October 2007 10:30 Boundary House DS0000027402.V352190.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 Boundary House DS0000027402.V352190.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. Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Boundary House Address Haveringland Road Felthorpe Norwich Norfolk NR10 4BZ 01603 754715 01603 400418 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) Mr Canabady Mauree Ms Sandra Bridgwood Debbie Judd – registration pending Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home may accommodate up to ten (10) people who have a Learning Disability, one of whom is over 65 years of age and is named in the Commission’s records. 27th November 2006 Date of last inspection Brief Description of the Service: Boundary House provides residential care for up to 10 adults with learning disabilities, it is situated on the outskirts of the village of Felthorpe, which is a few miles from the city of Norwich. The home is situated in extensive grounds containing portacabins, greenhouses and other outbuildings. Bedrooms are located on the ground and first floors. There are communal lounge, dining and kitchen areas. There are two bathrooms and one shower room. Service users living in the home access day services, including those operated by the proprietor in North Walsham. The home has its own transport. Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report includes information gathered about the service since the last key inspection (November 2006) and includes information from an unannounced visit to the Home carried out on 1st October 2007 between 10.30am and 4.25pm. During the visit the Inspector spoke to the manager and staff, observed staff supporting clients and looked at records. The Inspector spoke briefly to three of the clients but was unable to obtain much information relating to their views of the service that they receive. Eight comment cards were received from clients which were positive. The clients had been assisted by staff to complete these. One comment card was received from a relative and this was also positive, including the additional comment: “we are very pleased with the level of care and all aspects of the Home”. The Annual Quality Assurance Assessment (AQAA) was completed and returned to the Commission as requested. What the service does well: What has improved since the last inspection? The Home now has a permanent Manager. The use of agency staff has reduced recently. Some redecoration/refurbishment has taken place within the Home. The Home has an additional vehicle which enables the clients to go out more. Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 6 A more person centred approach is being used in the care planning process which encourages the views of the clients to be central to this process. The organisation plans to install internet access to enable improved communication within the organisation. 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. Boundary House DS0000027402.V352190.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 Boundary House DS0000027402.V352190.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate assessments, which include the views of the clients, are carried out prior to admission. EVIDENCE: One client has moved to the Home since the last Inspection. Discussions with staff, the client and observations of records show that appropriate assessments were carried out prior to her moving despite the fact that this took place in a very short period of time as it was an emergency admission. Staff had information about how to meet the clients needs and the care plan was updated as necessary. Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The clients individual needs are assessed and the care plans and risk assessments contain guidance for staff about how to meet their needs. EVIDENCE: Two of the care plans were seen and these contain detailed guidance for staff about how to meet the needs of the clients. One of the care plans was much more detailed but this is because this client has lived at the Home for longer. The care plan seen for the client who recently moved to the Home has clearly been updated as further information has been gathered from the client about their needs. Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 10 The care plans are starting to become much more individual and personalised with more involvement of the clients in the process of putting them together and reviewing them. The Manager said that there are plans to start to use pictorial versions which will be much more accessible to some of the clients. At the last Inspection there were plans to introduce a more Person Centred Planning approach and this has started to be implemented although the majority of the staff still need to attend appropriate training to ensure consistency. Risks associated with the clients lives are recognised and the care plans include risk assessments with guidance for staff about how to manage risks appropriately. The Manager is aware of the need to balance protection for clients with enabling them to have choices in their lives. The Home provides support to people with challenging behaviours and the care care plans/risk assessments contain information about how to support individuals at these times. Discussions with staff show that the use of any physical interventions is kept to a minimum and that staff all receive appropriate training with regard to this. Several of the clients have autism and therefore have specific needs associated with this. The staff who spoke to the Inspector have a good understanding of the needs of the clients and about the care plans in place to meet these. Staff were seen to communicate positively with the clients. Staff receive training with regard to autism and communication. The Manager said that another member of staff will be attending Communication Co-ordinators training so that full communication assessments can be carried out for the clients. Staff were seen and heard to offer choices to the clients in a range of situation. Examples were given by staff about how different clients are able to make their own choices. Staff said that this is an area which has improved in the last year. Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 11 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 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The clients are supported to take part in a range of activities. The clients are supported to maintain contact with relatives. EVIDENCE: The clients take part in a range of activities during the week. Some attend the day service which is owned by the same organisation which is located in North Walsham. These clients are supported by staff from the Home whilst they are at the day centre. Some of the clients take part in horticultural activities which are located on the same site as the Home but staffed by a separate staff team. Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 12 Clients who are home during the day are supported by staff to take part in activities within the Home, to take part in general housework tasks and to go out into the wider community. The Home has recently had the use of a car as well as the mini bus that it has always had. During the week the mini bus is used at the day centre and so it is necessary for the Home to have the use of the second vehicle or clients are not able to access any other activities away from the Home due to the rural location of the Home. It is also important that the majority of the staff are drivers as the clients could become very isolated if they are not able to leave the Home. Three of the clients have 1:1 support from staff during the day and the rotas show that this staffing level is provided. This enables them to take part in activities. Due to the specific needs of clients it can be difficult to find suitable meaningful activities that they enjoy but the staff gave examples of how they continually try to enable this to happen. An improvement since the last Inspection is that there is now a more structured approach to activities within the Home for those clients who have not gone out during the week. Consideration could be given to the provision of more equipment so that the large garden area could be utilised more by those clients who enjoy physical activity. The clients comment cards were mixed in their views about whether there are good activities provided, with some stating that there are and some stating “sometimes”. The relatives comment card states that they are kept informed about issues affecting their relative and that the staff “keep family involved….we are very pleased with the level of care”. The care plans include information about the arrangements in place for the clients to maintain contact with people who are important to them. Improvements have been made in the opportunities that the clients have for making their own decisions about issues affecting them. The Person Centred Approach that the Manager advocates is an effective way for enabling the client to be at the centre of the care planning process and for encouraging staff to offer choices to the client in as many ways as possible. Some of the clients have communication difficulties and staff gave examples of the different ways in which they try to offer choices, rather than just through the use of verbal communication. One of the clients who spoke to the Inspector said that they enjoy their meals. Seven of the clients comment cards stated that they enjoy the food and one stated that they do “sometimes”. Clients are now more involved in choosing the menus and in shopping for food. The kitchen needs improvements which would enable the clients to more easily be involved in the preparation and cooking of meals. The menu was seen and this shows that the main meals are varied with the inclusion of fresh ingredients. However, the majority of Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 13 the “lighter” meals are sandwiches but it is not clear whether this is due to the clients choice or a lack of available alternatives. Clients have a choice about where they eat their meals as there are two lounge/diners in the Home. Clients can also have their meals at a separate time to the majority if that is easier for them. One of the clients asked the Manager to have lunch with him on the day of the Inspection which she did. Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personal and healthcare needs of the clients are met. Medication is managed safely and effectively. EVIDENCE: All eight of the clients comment cards state that they feel that they are well cared for. Six stated that they like living at the Home, one does “sometimes” and one stated “no” to this question. The relatives comment card states that they feel that their relatives needs are met and that the staff have the right skills and experience to do this. One of the clients told the Inspector that they like living at the Home and that the staff help her to do things. Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 15 The care plans contain details about how to meet individual clients personal and healthcare needs. These also include information about regular appointments with optician, dentist and other routine appointments. There is evidence of health/social care professionals being involved in the care planning process. The staff who spoke to the Inspector were sensitive to the issues of privacy and dignity when talking about providing care to the clients. Clients are encouraged to maintain and develop their independence with regard to personal care. The medication system in use was seen. Medication is stored appropriately and clear records are kept of medication received at the Home, administration of medication and any that is returned to the pharmacy. The recommendation for clearer PRN (as required) guidance has been met. Staff receive appropriate training and are only allowed to administer medication once they have received training and have been deemed competent to do so. The medication cupboard has been moved from its previous location to one which is more suitable. Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home has procedures in place and provides staff training which promote the protection of the clients. EVIDENCE: The Commission have not received any complaints about the Home and the Manager said that they have not received any either. The Home has a complaints procedure and even though this is available in alternative formats it is difficult to see how some of the clients would be able to make a complaint on their own behalf due to the communication difficulties. However, the ongoing work to improve communication and the involvement of the clients in decision making about their lives will increase the opportunities for issues that the clients are not happy about to be raised. Some of the clients were seen to freely go into the office when the Manager was there to speak to her about their day, or just to see what she was doing. The staff who spoke to the Inspector gave examples of how they would know that a client was not happy about something if they were unable to verbalise this. Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 17 The clients comment cards all state that the staff treat them well and that they feel well cared for. They also all state that they know who to talk to if they are not happy about something. Seven stated that they feel safe at the Home whilst one stated “sometimes” to this question. The relatives comment card stated that they are aware of the complaints procedure and that the staff “listen to what we have to say and note our comments”. The Home has policies and procedures relating to the protection of the clients. Training is provided to staff about the management of challenging behaviours, the use of physical interventions and also Safeguarding Adults. Staff who spoke to the Inspector were clear about the action they would take if they were concerned about the behaviour of any of the staff towards the clients. They were confident that the Manager and team leaders would deal with any concerns appropriately. Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home is fairly bare and not very homely but this is mainly due to the needs of the clients. EVIDENCE: The Inspector looked around the communal areas of the Home but did not see any of the bedrooms on this occasion. The Manager said that some of the bedrooms have been decorated and that new bedroom furniture has been purchased for some of the clients. Other improvements include the redecoration of the lounge on the first floor and the addition of photographs and pictures on the walls throughout the Home. Work has been carried out to meet the requirement to remove the unpleasant odour from two of the bathrooms. However, the bathrooms are rather bare and utilitarian and it is recommended that these are redecorated. Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 19 The kitchen is large but the layout of it is not conducive to the clients using this safely. The kitchen was very warm on the day of the Inspection and staff said that this was the usual situation as the boilers were located in the kitchen. Although the back door and windows can be opened the kitchen does not have a suitable system in place for monitoring/altering the temperature. Fresh fruit and vegetables are stored in the kitchen and the temperature on the day of the Inspection was too hot for this. The extractor fan for the oven is not working. It is required that the oven is mended. It is recommended that consideration is given to installing a suitable system for controlling the temperature in the kitchen. It is recommended that the kitchen is redecorated and refurbished. The laundry room is located in a separate outbuilding away from the Home. The condition of this building is poor with no proper floor covering and with the ceiling in a very poor condition. There is also no fire detection system in place. It is required that work is carried out to improve the condition of the laundry room and that a risk assessment is carried out with regard to the lack of fire detection in this area. Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff receive training and supervision which enables them to carry out their roles effectively. Appropriate recruitment procedures are followed. EVIDENCE: The clients comment cards all state that they feel well cared for and that the staff treat them well. The relatives comment card states that staff have the appropriate skills and experience to meet the needs of their relative. Staff were observed to communicate positively with the clients in a kind and relaxed manner. The rotas show that there are usually five staff on duty during the day and two waking night staff. This is also the staffing levels at weekends. Discussions with staff confirm that this is the staffing levels which are provided and that they are adequate to meet the needs of the clients. Three of the staff are responsible for providing one to one support for three clients at any one time Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 21 therefore, this leaves two members of staff to provide support to the other seven clients at weekends. This level of staffing does not enable much individualised support to take place when all of the clients are at home. The Manager said that there is currently one vacancy for care staff and that the use of agency staff has greatly reduced. The rotas and discussions with staff confirmed this. The Manager said that one of the reasons for recent high use of agency staff was to cover for staff holidays. The staff confirmed that when agency/bank staff are used they tend to be the same people so that they are already known to the clients. Two staff recruitment files were seen and these contain proof that the necessary checks have been undertaken. A visit to the personnel department in September 2006 was undertaken to inspect a selection of CRB disclosures as these are kept centrally rather than in the Home. The overall training record for the staff team shows that staff receive induction and training in mandatory subjects in a timely manner. Additional training is provided in subjects relevant to the needs of the clients, such as the use of physical interventions, diabetes, the Mental Capacity Act. Staff said that they enjoy the training and that it is relevant to their roles. Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home is well managed by the Manager. The health and safety needs of the clients and staff are addressed. The Home has a process for measuring the quality of the service provided. Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 23 EVIDENCE: At the time of the last Inspection the Home was being managed by an acting manager as the previous manager had not returned to the post after maternity leave. The acting manager left the Home in December 2006 and Debbie Judd was asked to manage the Home on a temporary basis. Ms Judd was previously the registered manager at another Home within the organisation. The position was made permanent and at the time of the visit to the Home Ms Judd was going through the process of becoming the registered Manager for this Home, this process was completed very soon after the visit. Ms Judd has completed NVQ 4 in Care and intends to start the Registered Managers Award in January 2008. She has also attended the training that is provided to the whole team. The Manager is enthusiastic about her role and about the improvements that have already been achieved and those that the team wish to implement. She has high standards which she communicates well to the staff team. The staff spoke highly of the support that the Manager provides. The Home also has two team leaders, one of whom has been newly appointed to the role and one who has carried out this role for some time. Some management training is provided to the team leaders and the Managers within the organisation but this is currently being reviewed to ensure that the management teams within each Home receives adequate training. Staff meetings have taken place approximately twice per year and the records show that lots of issues are discussed at those times, including the needs of the clients, issues affecting the running of the Home and those affecting staff. Staff confirmed that supervision is provided by either the Manager or one of the team leaders. The Manager meets regularly with the other managers within the organisation but formal supervision is not provided to the Manager on a regularly enough basis. A recommendation is made about this. Last year the Home started to obtain the views of relatives and health/social care professionals as part of their ongoing quality assurance process. Questionnaires were sent to relatives in April 2007. Regular visits are now carried out to the Home as per Regulation 26. The AQAA form was completed to a satisfactory standard. An annual quality assurance report was sent to the Commission in August 2007. Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 24 In general, the health and safety needs of the clients and staff are recognised, assessed and action taken to meet them. A selection of records were seen and these show that equipment is regularly serviced and maintained. The recommendation made at the last Inspection has been met and the names of staff taking part in fire drills are now recorded. The organisation has arranged for an external company to carry out fire risk assessments at all of the Homes and the Manager is expecting this to take place shortly and will provide the Commission with a copy of any recommendations. As previously mentioned a requirement is made for a risk assessment to be carried out for the lack of fire detection equipment in the laundry room. Following the recent ban on smoking the area for staff to smoke in is near to the laundry room. This is another concern with regard to the lack of fire detection in this area. The laundry room is away from the house and therefore staff are not near enough to hear if other staff need them to return in a hurry. There are also possible issues about security at night. It is recommended that a risk assessment is carried out with regard to this situation. The head office for the organisation was based in temporary accommodation next door to the Home but they have recently moved to permanent office accommodation in Norwich. They are currently carrying out the planned provision of internet access for the Home managers across the organisation and the Manager expects this to take place within the next few weeks. This will be an improvement as communication will be much easier and faster. Boundary House DS0000027402.V352190.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 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 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 3 2 X X 2 X Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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. 2. 3. Standard YA24 YA30 YA42 Regulation 23 23 13 Requirement Timescale for action 31/10/07 It is required that the oven is repaired or replaced. It is required that the laundry 30/11/07 room is redecorated with appropriate flooring fitted. It is required that a risk 31/10/07 assessment is undertaken for the lack of fire detection in the laundry area. 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. 4. 5. Refer to Standard YA24 YA24 YA24 YA37 YA42 Good Practice Recommendations It is recommended that the bathrooms are redecorated in a more homely manner. It is recommended that the system for controlling the temperature in the kitchen is improved. It is recommended that the kitchen is refurbished. It is recommended that formal supervision is provided to the manager on at least a two monthly basis. It is recommended that a risk assessment is carried out for the staffs smoking area. Boundary House DS0000027402.V352190.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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