Inspection on 28/02/07 for Burnt Ash Hill, 94

This inspection was carried out on 28th February 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Burnt Ash Hill, 94 19/01/06

Burnt Ash Hill, 94 23/06/05

Burnt Ash Hill, 94 31/03/05

Burnt Ash Hill, 94 14/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Burnt Ash Hill, 94 London SE12 0HT Lead Inspector Ornella Cavuoto Unannounced Inspection 28th February 2007 10:00 Burnt Ash Hill, 94 DS0000053308.V331909.R02.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 Burnt Ash Hill, 94 DS0000053308.V331909.R02.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. Burnt Ash Hill, 94 DS0000053308.V331909.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burnt Ash Hill, 94 Address London SE12 0HT 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) 020 8851 3824 0208 694 2717 Aurora Charity Mrs Comfort Amoateng Care Home 6 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Burnt Ash Hill, 94 DS0000053308.V331909.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 6 people with a learning disability of whom 2 are over 65 years. 19th January 2006 Date of last inspection Brief Description of the Service: Burnt Ash Hill offers a care home to a maximum of six women and men with learning disabilities, who might also have other support needs. The overall aim is that of providing a service driven by the needs, abilities and aspirations of the service users. The home declares its core values to be: individual approaches, equal opportunities, inclusion and shared values. Burnt Ash Hill aims to achieve this by basing the service on a thorough assessment of needs, delivered in collaboration with external agencies. Staff would seek to advance the rights to privacy, dignity, independence, security, civil rights, choice and fulfilment in all aspects of their work and of the environment. The provider has recently changed its name to ‘Aurora Options’ from Aurora Charity. It also runs other homes. A chief executive and a service manager, to whom all the staff are ultimately accountable, direct the service. The day-to-day running of the home is delegated to a care manager. The premises are a large house, adapted to meet the needs of the residents group. All residents have their own bedroom. The ground floor is fully accessible to people using wheelchairs. The area is residential; it is served by public transport and has a selection of local shops. Burnt Ash Hill, 94 DS0000053308.V331909.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day. The registered manager was not available on the day the inspection took place but was spoken to shortly after the inspection and information that was not accessible during the inspection was sent to the Commission of Social Care Inspection (CSCI) as requested. Three of the service users were spoken to and case tracking methods were used with two of the service users. Three staff members were also spoken to. Other inspection methods included a tour of the premises and inspection of care records. What the service does well: Service users spoken to said they were happy living at the home. One service user said, “It is nice here, it is a nice home”. Observations of service users and their interactions with staff were warm and respectful. Service users’ needs are fully assessed and the home makes sure it is able to meet the needs of service users before they are offered a place at the home. Care plans are detailed with service users ‘ needs and goals included. These are regularly reviewed and updated. Service users are supported by staff to make decisions about their own lives and to lead independent and fulfilling lives as possible that involves responsible risk taking and to be engaged in a range of valued activities including education and paid employment. Service users are very much involved in the local community using local facilities such as pubs, restaurants, and shops amongst others. Service users are able to maintain family links and have been sensitively and appropriately supported by staff to develop personal relationships. Physical and emotional health care needs of service users are well met. Service users are well protected by the home’s medication policy and procedures and where appropriate service users are encouraged to take responsibility for their own medication. The home has effective complaints and adult protection procedures in place to protect service users and staff are kept well informed of adult protection procedures and to be aware of adult abuse. The home is well maintained, homely, comfortable and clean throughout. Staff are being supported to gain appropriate qualifications and generally have access to regular training in both mandatory topics and in topics specific to the needs of service users to ensure their individual and collective needs can be met. The home is overall well run and managed. Service users’ views are regularly sought by the home as part of monitoring the service provided. The health, safety and welfare of service users are protected. Burnt Ash Hill, 94 DS0000053308.V331909.R02.S.doc Version 5.2 Page 6 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. Burnt Ash Hill, 94 DS0000053308.V331909.R02.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 Burnt Ash Hill, 94 DS0000053308.V331909.R02.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Current and prospective service users have the information they need to make an informed choice about where to live. The home was committed to a full assessment of service users’ needs before they were offered a place at the home. EVIDENCE: There was evidence that the home had a comprehensive statement of purpose and service user guide that were in an accessible format. The service user guide included information about the fees charged by the home and services that were included. Current service users each had a folder containing both documents that were usually kept in their rooms although at the time the inspection was held these were in the process of being updated and so were stored in the office. There has not been an admission of a new service user to the home since 1998. Yet, the policy of the organisation in relation to any future admissions was that prospective service users would need to receive a full assessment by the appropriate professionals. Only then and if the home could meet the identified needs and aspirations of the individual, would the home confirm the offer of a place. Burnt Ash Hill, 94 DS0000053308.V331909.R02.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 &10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users had their needs and personal goals written down in a support plan that was in an accessible format and were kept by the service users themselves as well as being included in a more formal care plan that was in their personal files kept by the home. Service users are supported to make decisions about their own lives and to take risks so that they can live as independently as possible and lead fulfilling lifestyles. Information on service users is kept secure. EVIDENCE: The personal files of three of the service users living at the home were inspected. These all contained a detailed care plan that covered all aspects of personal and social support and healthcare needs. Individual specialist requirements were also addressed. There was evidence that the care plans had been reviewed six monthly and that service users had been involved in the reviewing process and they had been actively involved in making decisions about their care and in relation to their own lives. Any changes in support to be Burnt Ash Hill, 94 DS0000053308.V331909.R02.S.doc Version 5.2 Page 10 provided by staff or in service users’ personal goals and aspirations had been clearly reflected in an updated care plan. In addition, to these more formal care plans, there was evidence of personal support plans that had been drawn up with service users’ involvement that were in a simplified format and were kept by the service users themselves in their rooms. These contained comprehensive information about service users’ needs, preferences and lifestyles. At the previous inspection it was identified that certain parts of the plans had not been completed, specifically those that described service users’ wishes and goals in their own words. At this inspection it was found this had still not been fully addressed. However, the evidence in place demonstrated that this standard had clearly been met. Therefore, this is to be re-stated in this report as a recommendation (See Recommendations). As mentioned above there was evidence within the reviews held with service users and also in the drawing up of their own support plans that they had been actively involved and supported to make decisions about their own lives. A weekly meeting is also held where service users are involved in making decisions about social activities they want to be involved in and other aspects of the running of the home. It was also noted within the home’s annual development plan that one of the service users was to be included on the recruitment panel when interviews are to be held for new staff to be employed to work at the home. Discussions with service users confirmed that service users are supported to take risks to enable them to lead independent and fulfilling lives. Staff, as required provide advice and information. The personal files looked at all contained comprehensive risk assessments that had been regularly reviewed. A previous requirement that all service users’ information is stored and handled in a confidential manner had been met. The cupboard in the dining area used to store service users’ files was kept locked when not in use and files were not left unattended when staff were working on them. Burnt Ash Hill, 94 DS0000053308.V331909.R02.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 excellent. This judgement has been made using available evidence including a visit to this service. Service users have opportunities to be involved in education and training and also to undertake employment. Service users are part of and participate in the local community. Staff have supported service users to maintain family links and develop personal relationships. The home is run to promote service users’ independence. Service users are being encouraged to participate in cooking meals and to have a healthier diet but staff had not always consistently recorded meals eaten by service users. EVIDENCE: There was evidence available within service users’ personal support plans and within their personal files that demonstrated that service users are involved in a range of valued and fulfilling activities that include doing various classes at the day centres they attend such as cookery, pottery, creative dance, Burnt Ash Hill, 94 DS0000053308.V331909.R02.S.doc Version 5.2 Page 12 photography amongst others as well as attending community education classes in subjects that include computers, maths and English, assertion and life skills. Service users spoken to also confirmed this. One of the service users has a job locally whilst another service user was being supported to look into employment options. It was clearly evident from service users’ files and also in speaking to service users that they are very much part of the local community using the local shops, pubs, cinemas, leisure centres, theatres and some attend church. One service user who was spoken to discussed their relationship with their boyfriend and how they regularly visit their parents and have Sunday lunch. It was also evident from service users’ personal files that staff have sensitively and appropriately supported service users with developing and maintaining personal relationships. Observations during the inspection and again speaking to service users confirmed that the home is run to promote service users’ independence. Interactions between support staff and service users were warm and respectful. In addition, each service user has an intercom system in their rooms that is linked to the front door to uphold their privacy. In respect to meals, service users are encouraged to prepare their own breakfast and lunch. Service users were observed making their own sandwiches for lunch. It was reported in the evening that service users have up till recently mainly had microwave meals with additional vegetables being cooked to ensure service users are eating healthily although on Thursdays and Sundays a main meal is cooked that all the service users eat together. However, more recently, this had been changed with the staff trying to encourage more home cooking. At the weekly service user meeting, the menu for the week is discussed with service users being asked what they would like to eat on a particular day that they then have to help to prepare. Although generally records indicated that service users were eating a varied diet, the change introduced to reduce service users eating microwave meals is a positive one. Some gaps were identified in the records used by staff to write what service users have had to eat. It is important staff consistently record this information (See Requirements). Burnt Ash Hill, 94 DS0000053308.V331909.R02.S.doc Version 5.2 Page 13 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. Generally service users are supported with personal care in the way they prefer although the home needs to address the issue that appropriate staffing arrangements are not always in place for all service users to have their personal care needs met. The physical and emotional health needs are well met by the home. Where appropriate service users are supported to take responsibility for their own medication and service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: All service users were observed as well dressed and groomed. Service users where possible are encouraged to take responsibility for their personal hygiene with staff supervising and offering support as required. This is detailed in service users’ care plans. One of the service users spoken to confirmed how they choose their own clothes when getting dressed. Also, as mentioned previously interaction between staff and service users was observed as respectful and warm. There is a key worker system in place to ensure consistency of support and service users spoken to knew their key workers. Burnt Ash Hill, 94 DS0000053308.V331909.R02.S.doc Version 5.2 Page 14 However, at previous inspections concerns have been identified about the staffing arrangements of the home that these were such that at times only one member of staff was on duty and when the support worker on duty was male they may be required to support a female service user with intimate care. The provider was asked to carefully consider this arrangement in relation to their policy on safer working practices. This would be not only for the protection of service users but also to protect staff from any false allegations. At this inspection, the rota was inspected and it was noted that the situation with staffing generally was the same in that although there was a male support worker on duty alone for an early shift only very occasionally, this occurred more often on the late shift that covers the afternoon and evening shift including the sleep over. It is evident that this situation may prove difficult to address in relation to ensuring a female support worker is always available. Yet, to try to minimise any risks to female service users and also to protect the male workers from false allegations risk assessments in respect to having to give personal/intimate care should be drawn up (See Requirements). There was evidence within care plans and also for each service user there was an up to date record of appointments attended by service users with a range of different health professionals including GPs, chiropodists, dentists, opticians, audiologists, district nurses, dieticians amongst others. Staff had also written up a brief note on the outcome on each appointment attended. The home had a robust medication policy and procedures in place. It was reported that all permanent staff working at the home had undertaken medication training Module 1 via Lewisham Partnership and training records indicated one staff member had completed Module 2. One service user takes responsibility for taking their own medication. For other service users, a sample of Medication Administration Record (MAR) sheets were checked and were found to be accurate. Burnt Ash Hill, 94 DS0000053308.V331909.R02.S.doc Version 5.2 Page 15 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. Service users spoken to felt confident they could speak to staff about any complaints they may have. Service users are protected from abuse. EVIDENCE: Two of the service users spoken to stated would talk to the manager if they were unhappy or had concerns about living in the home. The service user guide contained information regarding advocacy. The home did have a document ‘We want to hear about what you think’ in an accessible format that was placed on the notice board in the hallway of the home. It was noted that the contact details of CSCI needed to be changed as the Southwark office has moved. It was reported this was in the process of being addressed as well as other details regarding changes within the organisation being altered within the document. The home had a complaints log in place but there had been no informal or formal complaints made since the last inspection. The home has a robust adult protection procedure that defines the different types of abuse and responsibilities of support staff and managers in reporting abuse. There is also a comprehensive whistle blowing policy. All staff have undertaken adult protection training and this is refreshed on an annual basis. Staff also have to sign that they have read the policy. There have been no adult protection investigations since the last inspection. In respect to service users finances, it was reported that two of the service users have an input in managing their own finances but staff take responsibility for managing the Burnt Ash Hill, 94 DS0000053308.V331909.R02.S.doc Version 5.2 Page 16 finances of the other service users for which there are robust systems and procedures in place to ensure these are kept in order. A sample of service users’ finances were checked and were all found to be accurate. Burnt Ash Hill, 94 DS0000053308.V331909.R02.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 &30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, safe and well -maintained environment. The home is clean and hygienic. EVIDENCE: The home is spacious, comfortable, well –maintained and decorated in a homely manner that meets with service users’ individual and collective needs. All the communal areas of the home that include a kitchen with an attached dining area and a separate lounge were clean and hygienic as were the service users bedrooms that were seen. These were very personalised and service users confirmed that they had chosen their own colour schemes. Burnt Ash Hill, 94 DS0000053308.V331909.R02.S.doc Version 5.2 Page 18 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 &35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 50 of staff presently working at the home have obtained or are in the process of obtaining a National Vocational Qualification (NVQ) or an appropriate equivalent qualification. An effective staff team generally supports service users. Service users are protected by the home’s recruitment practices. Staff have access to training to ensure the individual and collective needs of service users are effectively met. EVIDENCE: At present there are three permanent staff working at the home, three regular bank workers and three agency workers. Of those permanent workers it was reported that one has a BTEC qualification in Health and Social Care that is equivalent to a NVQ Level 2, one staff member is in the process of completing a NVQ Level 2 and one has completed a NVQ Level 3 and 4. In relation to the bank workers one is currently studying full time for a social work qualification, which is of a higher level than a NVQ. One of the agency workers is presently undertaking a NVQ Level 3 whilst another is doing an Access to Nursing course. Overall, this means that the home has met the 50 target specified within the Burnt Ash Hill, 94 DS0000053308.V331909.R02.S.doc Version 5.2 Page 19 National Minimum Standards that staff should have obtained or be working towards a NVQ or an equivalent qualification. In respect to staffing the permanent staff and some of the bank staff have worked at the home for a number of years and therefore they are experienced and have a good understanding of service users’ needs and preferences. However, as mentioned in respect to Standard 18 it was noted from the rotas in place that occasionally there is only one member of staff on duty. Previous inspections have noted concerns about this level of staffing being sufficient to meet service users needs. This was discussed with the registered manager shortly after the inspection was held. They reported that staffing levels are reviewed on a weekly basis. Following the weekly service user meeting when social activities and events are arranged staffing is looked at and if additional staff are needed if service users are going out and need to be accompanied this is then arranged. Copies of rotas sent to CSCI following the inspection confirmed this. There is also an on call system in place in cases of emergencies. Given these arrangements and the level of independence of the service users living at the home this standard is deemed met. A small sample of personnel records were checked following the inspection at the provider’s main Head Office as these could not be inspected on the day due to the registered manager not being present and the records not being accessible. These were found to include all the necessary documentation as required by regulation including an appropriate Enhanced Criminal Records Bureau (ECRB) check, two references and appropriate identification. Staffs’ training records were sent to CSCI following the inspection, as these were not available on the day. These indicated that staff had all undertaken mandatory training, which are automatically updated as required. In addition, staff had completed a range of training courses in topics such as handling violent and aggressive behaviour, sexuality and learning disabilities, person centred planning, hearing problems and solutions amongst others ensuring the individual and collective needs of service users are met. Burnt Ash Hill, 94 DS0000053308.V331909.R02.S.doc Version 5.2 Page 20 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. Service users benefit from a well run home. The views of service users are regularly obtained through surveys and a development plan drawn up based on the results. The health, safety and welfare of service users are promoted and protected. EVIDENCE: The present registered manager has worked for the organisation for nine years in different roles and has been in post as manager for three years. They are presently in the process of completing the required NVQ Level 4. It was evident in undertaking the inspection that the home was very well organised and well run. Service user surveys were seen that had been completed with service users in October 2006. All gave very positive feedback about living at the home and Burnt Ash Hill, 94 DS0000053308.V331909.R02.S.doc Version 5.2 Page 21 also about support received from staff. An annual development plan was also seen that was partly based on the results of the surveys and clearly set out aims and outcomes for service users. It was reported that surveys are also sent to relatives and professionals involved in the home but these are sent to the organisations Head Office and so were not seen. In addition, as mentioned previously within the report weekly service user meetings are held in which service users’ views are obtained and they are involved in aspects of the running of the home. Regular reviews at which service users attend and are actively involved are held. In relation to monthly provider visits there was evidence that these had been completed although these had not always been carried out regularly and copies of the reports had not been consistently sent to CSCI (See Requirements). The home had comprehensive health and safety policies in place. There was evidence of up to date maintenance certificates in respect to fire equipment, gas and electrical wiring. Fire alarm call points had been tested as required and regular fire drills had been undertaken. All staff complete fire safety training annually and other mandatory training such as moving and handling and food hygiene. Monthly water temperatures had been recorded. Finally there was a fire risk assessment that had been reviewed and general health and safety and infection control audits had been carried out regularly. Burnt Ash Hill, 94 DS0000053308.V331909.R02.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 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 4 X 3 3 LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 3 X 2 X X 3 X Burnt Ash Hill, 94 DS0000053308.V331909.R02.S.doc Version 5.2 Page 23 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 YA17 Regulation 16(2)(i) Requirement The registered manager must ensure that staff consistently record the meals prepared and eaten by service users so that it can be monitored that they are eating a sufficiently varied and nutritious diet. The registered manager must ensure that risk assessments are drawn up in respect to the issue that when male support workers are working alone they may have to provide support around personal/intimate care to female service users. The registered provider must ensure that monthly provider visits are carried out regularly and copies of reports are sent to CSCI. Timescale for action 30/06/07 2. YA18 12(4) 30/06/07 3. YA39 26 30/06/07 Burnt Ash Hill, 94 DS0000053308.V331909.R02.S.doc Version 5.2 Page 24 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 YA6 Good Practice Recommendations The Registered Manager should try to ensure that all areas of the service users’ support plans are completed Burnt Ash Hill, 94 DS0000053308.V331909.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup DA14 5RH 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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