Inspection on 27/03/07 for Carlene House

This inspection was carried out on 27th March 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 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

Carlene House 02/12/05

Carlene House 25/08/05

Carlene House 14/12/04

Carlene House 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 Carlene House 17 Woodcote Valley Road Purley Surrey CR8 3AL Lead Inspector David Halliwell Key Unannounced Inspection 27th March 2007 09:30 Carlene House DS0000025762.V326821.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 Carlene House DS0000025762.V326821.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. Carlene House DS0000025762.V326821.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carlene House Address 17 Woodcote Valley Road Purley Surrey CR8 3AL 020 8668 7676 020 8660 4237 marcel@fircroftservices.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Fircroft Services Limited New Manager applying for registration Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Carlene House DS0000025762.V326821.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd December 2005 Brief Description of the Service: Carlene House is a detached care home for ten adults with learning disabilities, aged between 18 years and 65 years. Situated in a quiet residential area of Purley, the home is well placed to access local transport links, amenities and resources. The home consists of ten single bedrooms, a good-sized lounge and dining area with an activities room on the second floor. The kitchen is spacious and there is a laundry room on the ground floor. Access to the first and second floors of the home is via a set of stairs. There are sufficient numbers of bathroom/shower and toilet facilities located throughout the home to meet the service users needs. The large landscaped garden is set out over two levels, with a raised lawn and patio area equipped with tables and chairs and barbecue facility. All service users attend day services and employment and the home offers a varied and structured programme of activities and outings. The home does not provide its own transport but supports service users to fully access various public transport services. The Manager advised the Inspector that the average price of a placement per week is £600. Carlene House DS0000025762.V326821.R01.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 visit undertaken by the new Inspector responsible for Carlton House. The Inspection covered all the key standards and involved a tour of the home, a review of all the homes records and interviews with staff. 3 service users were spoken with informally as a part of the tour of the home. 3 new recommendations have been made as a result of this inspection, the previous recommendation remains in place as it has not yet been met. Feedback on the inspection was given verbally to the Manager and to the Proprietor who was present during the inspection visit. The Inspector found the Manager, Proprietor, residents and staff very helpful and they are to be thanked for the assistance that they gave him over the course of this inspection visit. The Inspector was impressed by the commitment and enthusiasm of the management and of the staff group. The Manager informed the Inspector that the standard fees for a standard residential placement at this home are £600 per week. What the service does well: The home is able to demonstrate that it is assessing and meeting the needs of service users admitted to the home. Prospective service users, their relatives and friends are able to visit and to assess the quality, facilities and suitability of the home. The health care needs of service users are being very well met. Service users are living in a safe, well-maintained environment, with access to safe, pleasant and comfortable facilities. Service users generally presented as well settled in their environment, and very satisfied with the communal and personal facilities provided. The home is being managed the home in an open, professional and competent manner. Carlene House DS0000025762.V326821.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. Carlene House DS0000025762.V326821.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 Carlene House DS0000025762.V326821.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): Standard 2. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Residents may be assured that their needs will be thoroughly assessed and reviewed by their referring agencies, they may also be assured that their needs will continue to be fully assessed at Carlene House and that fully completed documentation will always be held on their files. EVIDENCE: Standard 2 – Four residents files were inspected at this inspection and three residents were spoken with informally. On inspection of the residents files, full needs assessments and care plan information were seen on each of these files to have been supplied by the referring agencies. Given the needs of the people living at Carlene House this information is as comprehensive and detailed in all aspects as would be expected. Needs assessments were also seen to have been carried out by key worker staff at Carlene House and these were seen on those files inspected. The Manager explained that the care plans drawn up by the unit are based on the information supplied by the referring agencies. Carlene House DS0000025762.V326821.R01.S.doc Version 5.2 Page 9 Evidence was also seen on the care plan and needs assessment documentation by the Inspector of the appropriate involvement in these processes of both the residents and their families or representatives. Residents told the Inspector that they are involved in their care plans reviews appropriately and are able to make their views and wishes known in the process. This was also confirmed by the Manager who was interviewed by the Inspector and who has overall responsibility for the care support of residents. Carlene House DS0000025762.V326821.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): Standards 6, 7 & 9. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the inspection visit to this service. The individual service user plans seen by the Inspector on the resident’s files did fully reflect the assessed and changing needs and personal goals of the residents. The care planning process is well managed and ensures a very personalised and consistently high level of service provision for the people living in the home. Service users can be assured that they will be supported to make decisions about their lives with assistance as needed and that they will be supported to take risks as part of an independent lifestyle so that independence is maximised as far as possible. EVIDENCE: All of the service users have a plan of care that reflects their identified needs. Records on the resident’s files sampled, indicated that service users are fully Carlene House DS0000025762.V326821.R01.S.doc Version 5.2 Page 11 involved in their individual planning meetings and supported to achieve their personal goals and aspirations. It is clear that staff work closely with each individual, their family and significant others, such as the day service, to ensure their preferences are responded to appropriately and the people important to them are involved with their planning of care. Daily records are also kept which highlight progress; achievements and any activities participated in. Service users’ care plans were seen to have been reviewed on a six monthly basis, and provide detailed information relating to users’ support needs and short-term goals throughout the year. Person centred planning continues to progress further and each service user now has a health action plan booklet. Pictures, symbols and photos are included to make them more accessible to those service users who have limited verbal communication. This is good practice, making the care plan more meaningful to them and valuing their input to it. Records show that staff encourage and promote independence in all aspects of people’s lives. The Manager told the Inspector that through regular house meetings with service users, relevant issues are discussed concerning all aspects of life in the home and in relation to individual needs. Care plans illustrate detailed risk assessments for each service user that are reviewed regularly and show that action is taken to minimise risk, whilst encouraging independence for individuals. These cover a variety of different areas for each individual, for example, cooking and going out in the community. Carlene House DS0000025762.V326821.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): Standard 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Residents are able to take part in age and culturally appropriate activities and are to a reasonable extent involved in local activities. Residents have appropriate relationships and their rights and responsibilities in their daily lives are recognised and respected by the staff in the unit. Residents are offered a healthy diet and they are assisted in learning cooking and food preparation skills. EVIDENCE: Carlene House places a strong emphasis on community presence and involvement for the service users for which the home is again commended. Records and observation showed that service users are offered choices of activities and supported to engage in their preferred interests and hobbies. Activity plans are flexible so that daily programmes can alter if service users Carlene House DS0000025762.V326821.R01.S.doc Version 5.2 Page 13 wish to do something different. The home does not have its own transport but service users regularly use public transport services including bus, tram and train. Community activities include swimming, social clubs, Rangers group, bingo, horse riding, trips to local pubs and restaurants. The home offers a wide range of in house entertainment facilities such as television, videos, music system, art and craft activities and jigsaws, computer and board games. Meetings are held monthly for the service users. Minutes showed that service users have opportunities for discussing and planning activities. Service users spoke favourably about these events and it was clear that their views have an influence on the way the activities are organised and the way the home is run. Service users returned from their respective colleges and day centres during the course of the inspection. On arrival, staff supported individuals to follow their chosen interests and routines. In view of the extensive activities provided and concise standard of record keeping, standards 12 and 13 have again been assessed as exceeded on this occasion. The Manager told the Inspector that service users do keep in regular contact with their families and friends. Staff encourage the residents to keep and maintain contacts with family and friends so that service users do benefit from having appropriate relationships. There is a visitor’s room in the house that can be used by visitors who wish to see their relatives in the house. Policies seen by the Inspector to be established within the unit ensure that service users rights to privacy, respect and dignity are respected. Residents who were interviewed also confirmed that they felt staff respected these rights. Residents said that they have a key to their own bedrooms, their mail is unopened, their preferred form of address is used by staff and staff do knock on their doors before entering. The Inspector observed staff to be interacting with residents in a friendly and respectful manner. With regards to meals and meal times there is a planned and varied menu which residents told the Inspector they enjoy. The Inspector saw suitably planned menus for the week ahead. Specific needs are catered for and alternative choices are provided. Residents are able to state their preferences when the menus are planned and there are discussions about this at the residents community meetings, which are held regularly. Carlene House DS0000025762.V326821.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): Standards 18, 19, and 20. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users can be assured that they will receive personal support in the way that they prefer and require. Their physical and emotional needs will be met. Service users can rely on the home providing a well-managed service with regards to medication although greater attention needs to be paid to the completion of records by staff. EVIDENCE: Records examined confirmed that arrangements are in place for meeting healthcare needs. Service users are supported to access a range of NHS facilities e.g. GP, Consultant, dental, chiropodist, optician and physiotherapy services. “Health action plan” record books are in place for each service user. Information relating to personal and healthcare needs including both routine and one off health interventions were well recorded. Care plans and specific strategies identify individual and specialist needs, which also reflect any Carlene House DS0000025762.V326821.R01.S.doc Version 5.2 Page 15 changing needs. Detailed records were in place and involvement with specialist services highlighted where necessary. Medication administration sheets were noted to be accurate and staff have undertaken accredited training. The home receives three monthly audits from the pharmacist to further ensure that medication practices are undertaken appropriately. Records showed that no concerns have been highlighted. Carlene House DS0000025762.V326821.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): Standards 22 & 23. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Arrangements for complaints and protection from abuse are well managed and ensure that service users feel listened to and safe. EVIDENCE: The complaints procedure contains all of the relevant and necessary information and is readily available to the people who live there, their relatives and other visitors. A log of complaints is kept in a book and no complaints had been made about the home since the last inspection. Service users are aware of who to go to if they feel unhappy and are provided with the necessary support to air their views or concerns. The manager has completed Croydon’s Training for Trainers adult protection course, and is able to deliver this training to the home’s staff. Records confirmed that staff are properly inducted on abuse awareness and policies and procedures regarding the protection of vulnerable adults. Carlene House DS0000025762.V326821.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): Standards 24, & 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users may be assured that they do live in a safe and comfortable house that is also clean and hygienic. EVIDENCE: A tour of the premises was undertaken by the Inspector as a part of this inspection and the home was seen to be clean and tidy in all areas. All areas of the home are accessible to the residents. The general condition of the home and the facilities is good; communal areas and bedrooms are kept clean and odour-free. Staff provide a ‘homely’ touch through supplementary decoration and ornaments / flower decorations and pictures hanging on all the walls. Carlene House DS0000025762.V326821.R01.S.doc Version 5.2 Page 18 The Manager showed the Inspector the fire records for the home and the last fire risk assessment was carried out satisfactorily in January 2007. Records were also shown to the Inspector by the Manager for other safety checks that have been carried out this year and that are part of a regular process of checks carried out to help ensure the safety of the residents. Records of the following satisfactory checks were seen: • Fire extinguishers – July 2006 • Fire bells – July 2006 • Emergency lighting – July 2006 • Environmental health has still not visited this home although the Manager and the Proprietor advised the Inspector that they have been requested to do so on several occasions. It is again recommended that EH be requested to make a visit. Checks on the hot water outlets are also checked. Although the bathroom outlets are being checked weekly not all the hot water taps in residents bedrooms are being checked weekly. It is therefore recommended that a system similar to that discussed with the Manager is devised so that there can be surety that all the hot water taps/ outlets have been checked at least once every month and full records made of these checks including details of what tap was checked when and what the temperature actually was recorded as being at the time of the check. As already indicated above, the home was found at this inspection to be clean, tidy and free from offensive odours. The Inspector toured the unit together with the Registered Manager and inspected all areas of the home. Several of the service users bedrooms were seen and were found to be clean and tidy and all the residents spoken to by the Inspector said that their bedrooms are decorated and furnished as they would wish. The Manager showed the Inspector the home’s infection control procedure, which seems to be effective. Staff interviewed confirmed that they are issued with appropriate clothing and equipment for them to carry out their work appropriately It is recommended that the laundry room floor needs to have an impermeable floor laid down to prevent water ingress and easy cleaning. Carlene House DS0000025762.V326821.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): Standards 32, 34, & 35. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users benefit from a competent and knowledgeable staff team, who are provided with the necessary training and guidance to support their needs. Recruitment practices are securely managed to maximise protection for the service users. EVIDENCE: Despite the recent change in the Manager’s post staff turn over at the home remains low that results in stability and consistency of care for the residents. The new manager reported that no staff had left since the last inspection. Service users appeared comfortable, and staff members have clearly established positive and cooperative relationships with each individual. Staff are provided with good support and the necessary training to meet the service users collective and individual needs. Examples include training in the Protection of Vulnerable Adults, food hygene, health and safety and the safe handling and administration of medication. Carlene House DS0000025762.V326821.R01.S.doc Version 5.2 Page 20 The Manager told the Inspector that it has always been management practice in this home to ensure that staff keep up to date on current issues and practice. Staff meetings are regular, held on a monthly basis and in depth consultations about the home’s care practices and service users needs are routinely discussed. Records and observation showed that good communication processes are upheld in this home. Service users feedback on staff was very positive and observations showed that staff respect their individuality as well as demonstrate an understanding of their specific needs. The Inspector saw records that confirmed that new CRB/POVA checks are obtained before new staff commence work and that for all 4 staff there are appropriate CRB certificates. Recruitment practices are well managed and the home has amended its policies to ensure that new police checks are carried out on any future employees. Carlene House DS0000025762.V326821.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): Standards 37, 39 and 42. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. The Manager and the staff work hard to ensure that service users benefit from a well run, competently managed, open and safe environment. Service users can be assured that their views underpin monitoring and review of the developments within the home. Service users can be assured that their welfare, health and safety is safeguarded through the home’s adherence to appropriate guidance and regulations concerning best safety practice. EVIDENCE: Carlene House DS0000025762.V326821.R01.S.doc Version 5.2 Page 22 The Manager has only recently been appointed as Manager at Carlene House in the last 3 weeks and is therefore new to this post. She told the Inspector however that previous to this appointment she held a Deputy Managers post in a care home for 2 years and therefore should have the necessary experience to undertake this role. The Manager informed the Inspector that she has enrolled to undertake the NVQ level 4 training which she is due to start in April 2007. She said she is working to achieve the RM Award. The Manager also said she has an appropriate JD for her post and is being well supported by the Proprietor by supervision. This was confirmed by the Proprietor to the Inspector in discussion. The Manager showed the Inspector the minutes of the staff team meetings that are held every 2 months. The minutes demonstrated that these meetings are well attended. Evidence of residents meetings was also provided to the Inspector and these records show that they are held every 2 months and that a wide variety of relevant issues are raised and discussed by the staff and residents together. These include food and menu planning, social activities, new residents and impending visits by any of the health professionals that visit the home regularly. Monitoring of this agency, quality assurance [QA], is through formal and informal consultation with service users and from visiting relatives and professionals. Feedback forms are issued and questions asked focus on the key principles of the service e.g. privacy, dignity, independence, choice, rights and fulfilment. The information and feedback gathered from these sources is then analysed and forms the basis of the annual development plan that includes implementation targets, with dates as milestones that can be measured and monitored. Staff are allocated areas of responsibility and the management team monitors the progress being made. Residents are provided with information about all aspects of this process via residents meetings and newsletters. The Inspector would like to commend Carlene House on the excellent model for Quality Assurance and the detailed system that is in place for using the information gathered, to develop and improve services being provided and feedback given to service users on the progress made. The Inspector asked the Manager if there was a risk assessment for the building and was informed that this is carried out regularly on an almost monthly basis for the high risk areas such as the kitchen, the last assessment being completed in January 2007. Risk assessments for the building are useful in helping to assure the health and safety of the residents. Appropriate policies were seen in the manual for the unit at Carlene House covering health and safety; moving and handling; and fire safety. Carlene House DS0000025762.V326821.R01.S.doc Version 5.2 Page 23 The Manager informed the Inspector that all staff receive training in: • Moving and handling • Fire safety • First aid • Food hygene • Infection control. Cleaning materials and hazardous materials are being stored in a secure cupboard area in the laundry room. The Manager told the Inspector that a weekly health and safety check is carried out by staff in order to ensure that any potential hazards are identified and dealt with. Records of these checks were shown to the Inspector. The Manager said that regular checks are carried out on all the unit’s services such as gas, electrical systems, fire alarms, fire prevention systems and that daily records are kept for fridge and freezer temperatures (these were inspected and all seen to be within the acceptable temperature ranges). Food is being stored correctly and is labelled with dates of when food is opened and when it’s expiry date is. Accidents are being appropriately recorded and the Inspector saw the log for this. No accidents were recorded since the last inspection. A record is being properly kept of: • Weekly fire alarm tests • Monthly fire extinguisher checks • Fire practice drills. The Manager informed the Inspector that regular tests have not been carried out for emergency lighting. However it is necessary that 6 monthly tests are carried out for the emergency lighting and this is recommended. The Proprietor regularly visits the home and reviews and comments on the service. Regulation 26 reports compiled by the Registered Provider concerning the home should now be copied regularly to the Commission - as required under this Regulation. Carlene House DS0000025762.V326821.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 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 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 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Carlene House DS0000025762.V326821.R01.S.doc Version 5.2 Page 25 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. 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. 2. Refer to Standard YA24 YA30 Good Practice Recommendations Environmental health should visit the kitchen in the home to carry out an inspection. A system similar to that discussed with the Manager should be devised so that there can be surety that all the hot water taps/ outlets have been checked at least once every month and full records made of these checks including details of what tap was checked when and what the temperature actually was recorded as being at the time of the check. It is recommended that the laundry room floor needs to have an impermeable floor laid down to prevent water ingress and easy cleaning. The Manager informed the Inspector that regular tests have not been carried out for emergency lighting. However it is necessary that 6 monthly tests are carried out for the emergency lighting and this is recommended. 3. YA30 4. YA42 Carlene House DS0000025762.V326821.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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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