Inspection on 19/02/07 for Broadview (Anchor House)

This inspection was carried out on 19th February 2007.

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

The inspector 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

Broadview (Anchor House) 19/02/09

Broadview (Anchor House) 15/11/05

Broadview (Anchor House) 29/06/05

Broadview (Anchor House) 29/03/05

Broadview (Anchor House) 09/02/05

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

CARE HOME ADULTS 18-65 Broadview (Anchor House) 245 Brompton Farm Road Frindsbury Extra Rochester Kent ME2 3NW Lead Inspector Anne Butts Key Unannounced Inspection 19th February 2007 09:30 Broadview (Anchor House) DS0000029018.V316946.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 Broadview (Anchor House) DS0000029018.V316946.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. Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadview (Anchor House) Address 245 Brompton Farm Road Frindsbury Extra Rochester Kent ME2 3NW 01634 717295 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) Mrs Marian Parkinson Mr George Patrick Parkinson Mrs Barbara Buxton Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 Brief Description of the Service: Broadview is a care home providing care and accommodation for 3 younger adults who have a learning disability and some additional needs. The home is owned by Mr George and Mrs Marion Parkinson and Barbara Buxton is the registered manager. The home is part of a local organisation that also provides a small domiciliary service and supported living accommodation to younger adults. The home is situated in the outskirts of Frindsbury/Strood town centres. It is on a bus route and has access to local facilities; shops, a park and a pub are all within easy walking distance. The property is a small but spacious detached bungalow and all service users have their own bedroom and access to ample communal space. There is a well-tended garden to rear of the property that is accessible to wheelchair users. Parking is to the rear of the home and is accessed via a private road. The home displays inspection reports and information about their service and ensures service users and their relatives have access to this. Fees range from £750.00 - £1,900 per week. Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place over the course of one day. The Registered Manager was present for part of this visit and there were two members of staff on duty during the day. The aim of the visit was to carry out an inspection against the key standards of the National Minimum Standards for Younger Adults in accordance with the Inspecting for Better Lives (IBL) process. Time was spent reviewing a care plans and supporting assessment documents as well as a selection of staff files. Time was also spent talking to staff and service users and observing the interaction between them. Information was also collected from a pre-inspection questionnaire and feedback from other sources. Due to the needs of the service users in the home only one was able to speak to the inspector and she expressed how much she liked living in the home and that the staff were very nice. Throughout the visit the manager and staff were helpful and keen to identify any areas of improvement. At the last site there was one requirement and four recommendations made and all of these had been addressed. There has been one requirement and four recommendations made at this visit. Judgements have been made for each outcome area in this report and these have been made using the Key Lines of Regulatory Assessment (KLORA), which is guidance used to ensure that a fair and proportionate judgement is made in each outcome area. More information about KLORA’s can be found on the Commission for Social Care Inspection’s (CSCI) website. What the service does well: The home has been able to demonstrate that where they cannot meet the specific needs of an individual they work well with the Local Authority and family in ensuring that suitable alternative arrangements can be made. Staff have good relationships with service users and are able to communicate with each individual in a manner that supports their varied needs. Care plans are detailed with clear descriptions of guidance on how to care for the service users, and are tailored to individual needs. Service users benefit from their individual and diverse dietary or eating needs being fully catered for and monitored in order to promote healthy living. Personal care needs are well met with care plans specifying how to deliver the required support in a detailed and sensitive manner. Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 6 The ethos of the home is to promote and support people with their individual needs with the focus of the service being about the individual. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Broadview (Anchor House) DS0000029018.V316946.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 Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users would be better informed if the Service Users Guide were reviewed and updated. Service users can be confident that a comprehensive assessment of their needs is undertaken and that the home will support each individual in meeting these needs. EVIDENCE: The Statement of Purpose was not viewed, however it was noted that the Service Users Guide now contained out of date information – especially with regards to local facilities. It was recommended that this be updated and reviewed and the home could consider adding in more information in line with Standard One of the National Minimum Standards for Younger Adults. For a number of years the home had been fully occupied, and there had been no changes in service users. Last year one service user, however moved out of the home following the home’s recognition that they could no longer meet their specific needs. This was worked in conjunction with the Commissioners Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 9 of the individuals’ service and the family, and was managed appropriately. The home also kept the CSCI informed throughout the process. A new service user has subsequently moved into the home and although this was carried out under emergency circumstances that did not enable the home to follow their full procedures for arranging visits and the opportunity to spend at the home prior to moving in – the home was able to demonstrate that opportunities for this as far as was practicably possible had been arranged. Records of the pre-assessment process were available and these were supported by a complete assessment provided from the Local Authority. The assessment process includes individual needs in all areas as stated in Standard Two and the support that will be required in this area. The assessment process also identifies as to what an individual can manage for themselves and possible potential for development. This was seen to be an ongoing process, whereby regular reviews were being carried out to monitor any changing needs as the service user became more familiar with the home. Records demonstrated that the home is continually monitoring individual needs to ensure that they can meet any ongoing changes. There is a small stable staff group in place and they have undergone appropriate training in order to ensure that they have the skills to deliver good care and support. Observations throughout the visit showed that staff interacted well with service users. All three service users in the home have different levels of communication and staff were observed speaking and interacting with people in a manner that recognised individual diverse needs. Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from comprehensive care plans which are aimed at supporting them in meeting individual needs and preferences. However not all areas of risk are fully identified, which could result in some areas of service users’ safety being at risk. Staff support service users in making decisions and act upon the choices that are made. EVIDENCE: All service users in the home have a full and comprehensive plan of care in place. These are known as life books and service users are fully involved in this process. Personal files were viewed and they were seen to contain detailed information on individual service users. It was evident that these have as far as possible been prepared with the service user and one in particular was proud of her file. Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 11 These ‘Life Books’ are set out in sections with detailed information contained in each. The first section relates to individual skills – covering a wide range of daily living and personal skills and assessed abilities. It also sets out the potential for development through ongoing support. Also, dependent upon the needs of the individual (as with the most recent service user who has moved into the home), there is a descriptive daily care plan in place for regular personal care routines that identify how to fully support the individual. Importantly these take into account the preferences of the service user and are reviewed regularly and amended as further preferences are identified – particularly important with the newest service user who has very limited communication skills. There were detailed descriptions of guidance on how to care for the service user, and clear evidence of making informed decisions. Care plans ensured that all identified areas of support had the needs with supporting aims and objectives. It was evident that the care plans are tailored to each individual and where there are limited communication skills – then set routines and guidelines within these care plans are more in-depth, and for service users who have a greater degree of dependency they are less complex and therefore taking into account individual needs. Service users are regularly consulted about the events of the home and a representative for the home attends meetings for the larger organisation. There are comprehensive risk assessments in place – although for individuals there are some key areas not risk assessed. It was evident that the home had considered the various risks, as there was some detail within the actual care plan format. The home must ensure, however, that there are detailed risk assessments for all areas of support where there are possible hazards especially with regards to movement and handling. Records are now stored more securely at they are stored within a locked cabinet. Service users have access to their own records and there is a confidentiality policy in place. Service users are offered a key to access their own records should they so wish. Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a home that promotes individual choice and ensures that their quality of life is maintained, by supporting them in accessing a range of activities or life choices in accordance with their needs. Meals and mealtimes benefit service users by being flexible and tailored to meet individual diverse and varied needs. EVIDENCE: There are three service users in the home, one of whom is reasonably independent, whilst the remaining service users have more complex needs. The home is committed to enabling people to develop their communication, social and emotional living skills as well as promoting their independency in managing as much of their lives as they are able. Individuals’ daily lives are ‘about them’ and any activities that they wish to participate in are of their own Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 13 choice. During the visit staff were observed promoting individual choices and listening to their preferences. One service user regularly goes to college and also works in the main office of the organisation helping out with general administration duties such as photocopying, answering the phone etc. Risks assessments are in place to support independent travel where appropriate. Where possible and abilities allow, service users are promoted in assisting with general household duties including shopping, cooking and doing their own washing. The involvement of family, friends and advocates is promoted and families are invited to attend reviews. Visitors are welcome at any time and at least one service user visits her family and stays over on a regular basis. The home also maintains close contact in order to ensure families are aware of any changing needs or concerns with regards to individuals, and this in done in agreement with individuals. Although there are only three people, all service users are very individual in needs and preferences with regards to eating. The home has allowed for in that all meals and mealtimes are very flexible and service users are individually catered for. One service user has swallow reflex problems and is mainly fed via a ‘peg feed’ - there is a risk assessment in place for recognising when this service user is able to try small amounts of specially prepared foods and good records are maintained. This allows the service user the opportunity to enjoy a meal on occasions. Staff have had training with regards to the ‘peg feed’ and also specialised training in recognising any swallow reflex difficulties. Another service user prefers to maintain a diet that consists of more convenience and quick foods such as chips, beef burgers etc. The home is working closely with the service user, family and dietician in order to try to promote and maintain a healthy diet and is making use of low fat and healthy options where possible. Observations during lunchtime also evidenced that staff were sensitive and discreet in their support. There are no pre-planned menus as such, due to the varying needs of individual people – but records showed that individuals take part in the planning of the shopping and can then choose what they prefer to eat on any given day. Broadview (Anchor House) DS0000029018.V316946.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 and 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home places a high value in supporting service users with their personal care needs and individuals benefit from this. Healthcare needs are well met, although improved recording in some areas would further ensure that individual needs are monitored and addressed so as to further promote their well-being. The systems and structures for supporting people with their medication promotes their safety and welfare. EVIDENCE: The three service users in the home have varied dependent needs in regards to their personal care – varying from only needing prompting to full support required. Care plans all showed how to support individuals in accordance with these needs and detailed how this should be delivered. These plans also identified as to how promote the inclusion of each person and where possible allow for as much independence or supporting of increasing their skills as Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 15 possible. recorded. The approach was person centred and outcomes were clearly Healthcare needs are well met with clear records of involvement from various health professionals including G.P.; dentist, optician and specialist nurses such as the stoma care nurse and diabetes nurse amongst others. One service user has a stoma, and all staff are trained in how to provide care and support in this area. There was some concern raised with regards to the recording of this, and it is acknowledged that this is maintained for healthcare reasons – however it was recommended that these details are recorded in a more sensitive manner so as to maintain privacy and dignity. It should be noted that this manner of recording was the only area identified that did not fully promote individuals dignity. One other concern was raised with regards to the emotional healthcare of one individual – records evidenced that this service user could on occasions display some challenging behaviour including ‘throwing’ herself to the floor. Daily records fully recorded this and also identified as to when and if any bruising had occurred as a result. However further supporting documentation such as incident recording and identifying onto a ‘body map’ and also full circumstances that could result in this behaviour were not in place. Discussions were held around this with the manager and with regards to ensuring that these incidents are fully recorded, including a risk assessment and positive action taken to reduce or manage this. A requirement has been made with regards to this. Overall, however, the healthcare needs of the service users are well maintained including the monitoring and working with the specialist nurse in supporting a service user who may have developed diabetes and ensuring that they are monitoring, accessing professional services and developing a strategy that will support the individual through a difficult time of change. Medication is well managed with good records being maintained. There are individual records kept in each service users’ file and the relevant information leaflets for each individual prescribed medication are in place. The home keeps a record of medication received into the home – although a good practice recommendation is being made that a member of staff signs to say that they are correct. Good examples of protocols regarding medication that needed to be taken as and when were also seen. The home has also good procedures in place for monitoring any illness and end of life issues and this has been dealt with in a sensitive and caring manner that recognises the capabilities and understanding of the service user and takes into account theirs and/or their families’ wishes. Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a clear and effective complaints system in place and service users are protected by robust adult protection policies and procedures. EVIDENCE: The home has a detailed complaints procedure that iso available in a format appropriate to the client group. A copy of this procedure was seen to contain appropriate timescales for responses to complaints. Any complaints are recorded and then actioned upon – and following a recommendation at the last visit, these records are now more detailed. Since the last inspection the home has undergone some experiences, whereby, they have needed to ensure the protection of service users in the home and also recognise where they are unable to fully meet those of an individual. Records, and constant communication with the relevant authorities have ensured that this was managed to the best of the homes ability and that all service users are being protected. The home ensures that all staff are fully checked through the Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) system prior to working with service users. The manager is also a trained person in training staff in Adult Protection procedures and the home place a high emphasis on ensuring the safety and well being of those living in the home. Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a well-maintained and homely environment that offers privacy and comfort EVIDENCE: This is a small well-maintained bungalow situated on the outskirts of Strood. Overall the environment is comfortable and mainly suits the needs of the service users living in the home. One service user has a specially adapted wheelchair to suit her needs and this means that doors are only just at an adequate width. The home is aware of this and is currently looking at the appropriate adaptations for this. Access via the front of the property is not disabled friendly – but there is full disabled access from the rear of the property via a small private road. The home does not promote the use of the front of the property. Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 18 Although only one bedroom was viewed as part of this site visit – it was evident through this and the communal living space that this is very much the home of the people who are living in it and all service users were observed to be relaxed and comfortable in the home. There are good records now being maintained with regards to the monitoring of water, fridge and freezer temperatures and any specialist equipment in the home such as a hoist are only used by staff who are trained to do so and are serviced on a regular basis. Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 19 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, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that their care and support needs are met by trained and competent staff, who respect their preferences and choices. EVIDENCE: Full staff details are held securely within the managers’ office, and a sample of records was viewed. There isn’t a key worker system in place, but there is a small stable staff team who all work closely with the service users and support them in meeting their needs. The home carries out pre-employment checks on all prospective staff members with an application form being completed, two references and an enhanced Criminal records Bureau (CRB) check carried out. One application form did show some gaps in employment and it is recommended that the home records that they have clarified this with the individual – a recommendation is being to this effect. Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 20 There is a full structured induction workbook in place. The induction process also contains key policies and procedures and there is a workbook that accompanies this programme – which is then signed to say that the new member of staff is competent. Since the last visit and following a recommendation the induction book is now specific to a residential setting and is reflective of the care required within the home. There is an ongoing training programme in place and the home fully supports staff in ensuring that they are trained in the mandatory areas required plus additional specialist training in meeting the specific needs of the service users in the home. This specialist training includes stoma care, epilepsy, using a peg feed and equality and diversity training. All staff have completed an NVQ in care. Observations throughout the visit showed that staff related well with service users and interacted well responding on a one-to-one basis with each service user as needed. Staff confirmed that they felt well supported and that they had plenty of training opportunities. Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 21 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, 38, 39, 40 and 42 Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a manager who is clearly committed to safeguarding and promoting individuals independence, rights and choices and is assisted by a stable staff team who offer a good quality of support to the service users. Service users can be confident that their health, safety and welfare is promoted by the philosophies of the home and quality assurance processes support this. EVIDENCE: There is a registered manager in place who has worked at the home for a number of years. She has the appropriate NVQ qualifications and is also Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 22 trained as a trainer in areas such as Adult Protection and equality and diversity. She regularly undertakes ongoing training to update her skills. The home is well managed and is run in the best interests of the service users. The atmosphere within the home was relaxed and everybody interacted well together and service users are able to participate in the daily running. There is a quality assurance process that includes seeking the views of the service users, families, health professionals and commissioners of the service. Individual views are listened to and acted upon. There are regular monthly health and safety audit checks ensuring that all equipment is regularly serviced and maintained safely. Staff are fully supported through the training programme and ongoing supervision. The home maintains good records for service users especially with regards to their daily care – it was noted however that some charts were not always completed fully and discussions were held around the manager ensuring that staff fully complete the daily records. Policies and procedures are included in the handbook and induction booklet, with a full set available in the office. These are now more reflective of the residential setting. Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 23 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 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 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 4 3 3 3 3 4 3 3 X 3 3 Broadview (Anchor House) DS0000029018.V316946.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA19 Regulation 17 (1) (a) Sch. 3 (3) (m) (o) Requirement Full records must be kept of any incident regarding a service user and show the positive action that the home has taken to address this. Timescale for action 15/04/07 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 YA1 Good Practice Recommendations It is recommended that the Service Users Guide is reviewed and updated. It would benefit from containing more information as outlined in Standard One of the National Minimum Standards for Younger Adults. It is strongly recommended that when carrying out risk assessments that all areas that may pose a hazard to service users are considered and full outcomes recorded on how to reduce these risks. It is recommended that intimate personal care records are maintained in a manner that respects the dignity of service users. It is recommended that any gaps in employment are explored and clarified at interview stage. It is recommended that where there are systems in place DS0000029018.V316946.R01.S.doc Version 5.2 Page 25 2. YA9 3. 4. 5. YA19 YA34 YA41 Broadview (Anchor House) for recording support provided to service users then these are fully completed in line with the organisational procedures. 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