Inspection on 25/04/07 for Camberwell New Road, 212a

This inspection was carried out on 25th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Camberwell New Road, 212a 30/01/06

Camberwell New Road, 212a 27/09/05

Camberwell New Road, 212a 21/03/05

Camberwell New Road, 212a 04/11/04

Camberwell New Road, 212a 18/03/04

Similar services:

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Norbury Crescent (30)

Edenvale

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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 Camberwell New Road, 212a Camberwell London SE5 0RR Lead Inspector Lynne Field Unannounced Inspection 25th April & 1st May 2007 10:00 DS0000022721.V332572.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 DS0000022721.V332572.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. DS0000022721.V332572.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Camberwell New Road, 212a Address Camberwell London SE5 0RR 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) 0207 582 1963 0207 582 1963 cnr@southsidepartnership.org.uk www.southsidepartnership.org.uk Southside Partnership Mark Ashley Wallis Care Home 5 Category(ies) of Learning disability (5) registration, with number of places DS0000022721.V332572.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2006 Brief Description of the Service: 212a Camberwell New Road is a home for 5 adults with learning disabilities run by Southside Partnership, a large voluntary organisation. It is accessed from outside via a flight of steps into a large communal hall which is shared with the housing association tenants who occupy flats on the first and second floors. The home comprises the ground and basement floors of a large four-storey house, which is a listed building owned by Hyde Housing Association. There is a small hallway, which leads into the large lounge/diner; the kitchen is off this room. On the other side of the hallway is another lounge. Off this lounge is a residents’ bedroom, which has an en-suite. Partitioning off part of the original lounge created this. There is a separate toilet on this floor. A flight of stairs leads to the basement floor of the home, where there are four single bedrooms, a bathroom with toilet, a small office and a shower room. This floor leads out to the large back garden; the front part is used by the home. The stairs inside and outside of the home make this home unsuitable for residents’ with mobility problems or dependent upon wheelchairs. The registered manager said the current fees payable for the resident is in the range of £359-90 per week. DS0000022721.V332572.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out on the 25th April and 1st May 2007. The registered manager and the deputy manager were present and took part in the inspection process. The inspector spoke to the registered manager and the deputy manager about how the home was developing and systems that are in place to ensure the residents are given the service they want and need. During a tour of the home the inspector met and spoke to four residents, the fifth resident was in hospital. The inspection included a tour of the home, garden and the examination of records on care plans, medication records and the complaints book. Residents came and went during the inspection and the inspector was able to observe that the interaction between staff and residents was friendly and respectful. Residents have their own bedroom, and access to a range of homely communal areas. Appropriate professionals have been consulted and adaptations are being made to meet residents’ changing needs. The inspector visited the organisations head office to check staff files and training records and found them all in order apart from the retention and storage of CRBs. What the service does well: The residents said they liked living at the home, being supported by staff, being involved in a variety of activities and supported into maintaining relationships with friends and family. The home gives good individualised care to all residents and supports residents impartially when they are facing difficult times and decisions. The home strives to achieve its aims by providing a service tailored to meet individual needs, in collaboration with external agencies. Staff support the residents’ right to make choices for themselves by holding best interest meetings when necessary, to have a say in the service they receive and to develop socially and emotionally as members of the local community. Care planning records held at the home have been updated, are securely kept, and reflect the changing needs of each resident. Staff said they were well supported by management and received training that met their needs and enabled them to feel confident in their tasks. DS0000022721.V332572.R01.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. DS0000022721.V332572.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 DS0000022721.V332572.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): 1,2,3,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents’ needs and aspirations are assessed, so that a service tailored to their needs could be provided. EVIDENCE: The inspector was shown the statement of purpose and a resident’s guide, which includes the complaints procedure in the residents’ guide. The statement of purpose and residents’ guide is being updated to reflect the changes in the management of the service. There have been no recent admissions to the home. Should a vacancy arise, the registered manager said the home would follow the homes admissions procedure and the prospective resident would be invited to visit the home with family members or friends to help them decide if the home could meet their needs. A complete assessment based on personal history, care management assessment and a full needs assessment would be completed to ensure the home could meet the prospective residents needs before a place in the home was offered. DS0000022721.V332572.R01.S.doc Version 5.2 Page 9 The inspector saw evidence on present residents files that this was the procedure that was followed at the time they were admitted into the home. This included assessments from the residents’ care manager as well as the homes own assessments. The registered manager said prospective residents and their family would be invited to visit the home to look around and meet the present residents and staff. DS0000022721.V332572.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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care plans are thorough and reflect residents’ needs and goals. Routines in the home are user-led and residents are regularly consulted about decisions that affect them. Potential risks are identified and residents are supported to take risks within a risk management framework. EVIDENCE: Five residents’ files were inspected. The home does all it can to help resident’s make decisions for themselves by involving them in the development of the care plans and through person centred planning. Care plans give a thorough description of residents’ individual behaviours, reactions and preferences and how the resident likes to be treated. The inspector observed the care plans and DS0000022721.V332572.R01.S.doc Version 5.2 Page 11 the type of support the resident needs have been written pictures and an easy to read format as well as the more formal style for staff and record keeping. The inspector viewed individual risk assessments, which had been carried out, monitored and reviewed by the staff with residents every six months or when the need arises. Details of any changes to the risks are recorded in the residents care plans. One resident whose illness has reoccurred, was in hospital at the time of the inspection but due to return home at the end of the week. In the summer of 2006 the resident started to have symptoms to indicate her long-term illness had returned. The home made a referral to the community team and a psychologist provided support, community nurses were involved as well as a number of other professionals. The home called a Best Interest meeting involving the resident’s family and all professionals involved in the residents care and support. Health plans were discussed and one to one counselling provided to support and help the resident understand diagnosis. The ethics of someone sitting down with her and discussing the length of time the prognosis had given her was discussed. The issue of the residents emotional well being was also paramount and to support her to remain positive about her future life. Because the resident has lived in the home for a number of years, they want to stay where staff and residents know them till the end. The home has continued to monitor and reassess their needs. The residents’ bedroom was in the basement, which would be inaccessible to them because of their illness. Another resident, who is also her friend, offered to change bedrooms, but she in turn has some mobility problems. The inspector was told the home has involved an occupational therapist who has looked at all aspects of both residents mobility needs and has made recommendations about adaptations the home has made to aid the home meet the residents mobility needs safely. Full detailed risk assessments have been carried out. The inspector saw documentation to support this. The resident who had agreed to change rooms spoke to the inspector and said they “were happy to change rooms and liked their new room”. They has just visited the resident in hospital and said they “were pleased she was coming home” DS0000022721.V332572.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): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to take part in age, peer and culturally appropriate activities, leisure activities and are part of their local community. They are actively encouraged to develop daily living and social skills by the registered manager and staff of the home. EVIDENCE: Each resident has a weekly activity plan that is incorporated onto one overall plan in “easy to read format”. This helps resident’s know what each other is doing on that particular day. The plan is coded so staff know what the activity is aimed towards, for example “tidy bedroom” is about teaching residents “daily living skills” and “mathematics / writing skills / develop money skills” teaching session for all residents is “education and learning”. DS0000022721.V332572.R01.S.doc Version 5.2 Page 13 On the day of the inspection the one resident was going to visit the resident who was in hospital. They were planning to take her some flowers and other items she needed. The deputy manager said they had been visiting her every day. One resident told the inspector “he wanted to go tomorrow, it was his turn”. One resident showed the inspector the new flat screen television that was on a shelf below the old one. The deputy manager explained although he had wanted to buy a new television, and had chosen it, he still wanted to use his old one and no amount of discussion could make him change his mind. Residents all have a spiritual and religious needs assessment on their files. It’s a visual assessment as well as a verbal assessment that looks at and records how the resident responds when asked a series of questions relating to their spiritual and religious needs. The inspector was told residents were being supported to chair the residents meetings. The registered manager said although this is taking time, it has encouraged residents to speak up in the meetings about issues that concern them and helped them be more confident about speaking up for themselves. The inspector was shown a copy of the format used at the residents meetings and this has a set agenda as well as a section for any other business. Meal times are discussed in residents meetings, such as “do you like the food” and “do you like the menu”. Residents decide what is to be put on the menu at the meetings and the menu is reviewed every three months. Copies of the menu were given to the inspector and they were written in picture format, which makes them easy to read. DS0000022721.V332572.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): 18,19,20,21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is provided in a way that meets residents’ needs and preferences, with due regard to issues relating to same-gender care. Medication administration was found to be properly documented and is handled safely. The ageing, illness and death of residents are handled with respect. EVIDENCE: Care files contain information for staff about residents who need personal support with their preferred personal care routines. The inspector was told there is a key worker system is in operation, with each resident having two members of staff from within the team to co-ordinate their support and care planning. The inspector saw all residents have health action plans and these are reviewed every six months and evaluated. There is a record of health DS0000022721.V332572.R01.S.doc Version 5.2 Page 15 appointments attended. Residents are supported by staff to attend an appropriate range of healthcare appointments in line with their individual healthcare needs. After the appointment the outcome and any treatment needed is recorded in the residents’ health care file. The community nurse has been involved in the resident’s care that is in hospital. The inspector was told it has been agreed the nurse will come to see the resident when she comes home from hospital. The registered manager said when the resident agreed to change rooms, she needed an assessment for her to use the stairs and the occupational therapist came very quickly to do that. Risk assessments are in place for this and the inspector was told these would be reviewed at the same time as the care plan. There was a policy on administration of medications. Resident medication is stored securely in a locked medication cabinet in lounge. The inspector checked resident’s medication with a member of staff and all were found to be correct. All medication dispensed is double checked before being given to the resident. The deputy manager checks the medication on a weekly basis. The inspector saw a copy of the six monthly pharmacy inspection and was told this is followed up by a visit from the pharmacist to a staff meeting where staff can ask the pharmacist questions about anything they do not understand. All residents have a funeral plan. The registered manager said they tried to do this as sensitively as possible with residents and their families by asking what would they want if they were “not here”. One resident said they would like music and another said they wanted to be taken by bus because they liked buses. Another said they wanted flowers. DS0000022721.V332572.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. There are safeguards in place to protect the resident from abuse, neglect and self-harm. EVIDENCE: The home has a complaints policy, a copy of which is in the residents’ guide. There is a complaints policy and the inspector saw the complaints book. Three complaints have been recorded since the last inspection. These were from a tenant from an upstairs flat relating to the garden gate being left open and saying a resident had left rubbish in the garden. The deputy manager said he dealt with this by speaking to the tenant and the landlord. There was a record of the actions taken and outcomes recorded in the complaints book. The inspector was shown a copy of the home’s Adult Protection and Whistle Blowing policy, which conforms to Local Authority requirements. The organisation now refers staff to POVA as appropriate. None of the staff in the home have been referred for inclusion on the POVA list. From discussions that the Inspector had, staff demonstrated they were aware of gender care policies. Two resident’s accounts and records were inspected and were found to be in order. The inspector noted the financial records are locked away and only the DS0000022721.V332572.R01.S.doc Version 5.2 Page 17 registered manager and the deputy manager have access to the residents’ financial records. The deputy manager is the appointee to four of the residents. One resident is able to sign their own bankbook. The deputy manager said if a parent or family member wanted to see the residents’ financial records, the manager or deputy manager would consult with the resident to check if that information could be shared. So far none have asked to do this. DS0000022721.V332572.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): 24,25,26,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is safe and comfortable with adequate private and shared space, toilets and bathrooms. The home is well maintained and furnished. Residents bedrooms are comfortable and are decorated to reflect their personalities. The home takes appropriate advice to make it safe for residents who have mobility problems. EVIDENCE: The home occupies the basement and ground floor of a large four-storey house. The home is not suitable for people with mobility restrictions as there are stairs to the front door and inside to the basement facilities, and as the building is listed, this cannot be altered. The hallways, bathroom, shower room and the communal rooms have all been redecorated in the last year, making DS0000022721.V332572.R01.S.doc Version 5.2 Page 19 the home bright and cheerful. The occupational therapist has been advising the home how adaptations can help the resident coming out of hospital can access the home safely. Bedrooms are personalised and reflect the taste and interests of the resident and has a wash hand basin. Residents said they are happy with their bedrooms. The ground floor bedroom has en-suite facilities, and this is the bedroom the resident who is in hospital now has. The occupational therapist has made recommendations about adaptations that the home will need to make and these will be completed before the resident comes out from hospital. The inspector was told the bedrooms have been decorated and two have had new carpet. There is also a toilet with wash hand basin on this floor close to the communal rooms for use by all residents. The basement floor has a bathroom with toilet, and a separate shower room. Residents therefore have a choice of bath or shower, with both having suitable disability facilities. There is a very large garden to the rear of the home, which is accessed by steps from the basement area, and shared with the other housing association tenants. The deputy manager said they were starting to develop the garden again and grow their own vegetables as they have done in previous years. DS0000022721.V332572.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. Training needs for all staff, including bank staff, has been identified and is formally planned, including NVQ training for all staff, to ensure that 50 of the homes staff achieved NVQ level 2 or 3. Appropriately trained staff meets the residents’ individual needs. The recruitment procedures followed are safe, thorough and comply with legal requirements. EVIDENCE: On the first day of the inspection, the inspector visited the organisation’s head office where the staff files were kept. The organisation was holding an induction day for all staff that had recently joined the organisation. There is an induction checklist for support staff that the managers must follow to ensure all staff have the same induction standard. DS0000022721.V332572.R01.S.doc Version 5.2 Page 21 The inspector inspected all staff CRBS checks that were available. The human resources manager told the inspector they followed the CRB guidance and destroyed all CRB’s after six months but before CSCI has seen them. The guidance states that providers should retain the CRB’s for 6 months or until seen by CSCI (if that is longer). The organisation needs to follow the guidance on how long CRB’s need to be kept. The inspector was told the organisation is planning to keep copies of certain documents relating to staff in a locked cabinet in the home they are based at. They have written to all staff asking for written permission do this. Most staff have agreed but this will not be done until all staff have agreed. Staff are only appointed after CRB’s are in place and two references have been received from their previous employer. Even when staff transfers with in the organisation, references are still taken up. New staff is given a job description, a contract and must have medical checks. All staff is given a copy of the staff handbook, which was reviewed in April 2006. On the second day of the inspection at the home, the inspector spoke to three members of staff. They said they had supervision every month. This was recorded and they said they felt very supported by the registered manager and the deputy manager. Each member of staff has a staff training and development plan. Staff said they has been on a” Person Centred Active Support” which is a way of supporting residents to engage in meaningful activities and relationships rather than jus helping residents learn new skills. The staff said it helped them look at how they viewed activities. Staff has recently had training diversity and spiritual needs, advocacy, fire and food safety. Copies of certificates were in the two staff files the inspector viewed at the organisations head office. The inspector noted that the staff had not had any up date in adult protection issues and would recommend this be done, especially around the new legislation about “Capacity to consent”. The first part of the recruitment is an interview with Human Resources and Home Manager, which is about what they have actually done, and their work experiences. The second part involves the residents from various homes of the organisation. They ask questions from the resident’s point of view. The inspector was shown a copy of the recruitment questionnaire tool that is used to assess potential staff and ensures all potential staff are treated equally. The inspector was told that residents take part in the selection process of staff recruitment. Six staff has NVQ level 3 and one member of staff is currently studying to gain this qualification. DS0000022721.V332572.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): 37,38,39,40,41,42,43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know the home is well managed and planned. Working practices and associated records ensure that the health and safety of residents is promoted. EVIDENCE: In the past two years the home has had a series of managers but it now appears to be stable. On the day of the inspection the registered manager and the deputy manager were there. The registered manager told the inspector he worked three days at the home and the other two days as a “patch manager”. He explained that the deputy DS0000022721.V332572.R01.S.doc Version 5.2 Page 23 manager had agreed to act up as the home manager for the two days the manager is in his other role as patch manager. This has been formalised and the inspector saw a copy of the contract that the deputy manager had signed to agree to the terms and conditions being changed to his contract. The registered manager told the inspector he had recently gone through the application process to become the registered manager of the home and had been accepted. The inspector noted that the certificate in the home did not reflect this and since the inspection the registered manager has contacted CSCI to say it has now been changed. The registered provider has been conducting monthly, unannounced visits to review the service and copies of the reports have been sent to CSCI to evidence the provider’s monitoring of the service. The inspector was shown a copy of the organisations business plan and saw a copy of the Camberwell New Road business plan that is evidence based. This included the two resident satisfaction survey forms that were devised and were given to the residents. The inspector saw copies of the completed surveys as well as copies of the carers quarterly feed back sheets, which were all very positive about the service. The home had a policy on health and safety and the inspector viewed health & safety records held in the home. A complete health and safety audit of the home was conducted in September 2006. The registered manager confirmed that there were regular checks at the required intervals, by external contractors, for servicing the fire safety system, the boiler, central heating system and the emergency call system. Certification was in place regarding the Landlord’s Record of Gas Safety, Portable Electrical Appliance testing, and Certificate of Electrical Installation. Records showed that regular checks of the fire alarm call points were made and that fire drills were conducted. The door guard batteries are checked and changed at regular intervals. There is fire risk assessment was reviewed in September 2006 and the LFEPA conducted an inspection in September 2006. It has been recommended the fire panel be replaced and up graded because it is old and keeps going off. This is still under review by Hyde, who are the landlords. Staff confirmed that they attended mandatory health and safety training, which included fire safety and staff training records confirmed this. DS0000022721.V332572.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 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 3 26 3 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 3 X LIFESTYLES Standard No Score 11 x 12 3 13 3 14 X 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 3 3 4 3 3 3 4 4 DS0000022721.V332572.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA34 Good Practice Recommendations The organisation needs to follow the guidance which states “providers should retain the CRB’s for 6 months or until seen by CSCI (if that is longer)” The staff would benefit from having up to date training in adult protection issues and procedures. 2 YA35 DS0000022721.V332572.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000022721.V332572.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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