Inspection on 17/04/07 for Church Road Respite Service

This inspection was carried out on 17th 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Church Road Respite Service 13/12/05

Church Road Respite Service 04/11/04

Church Road Respite Service 20/04/04

Church Road Respite Service 07/10/03

Church Road Respite Service 13/02/03

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

CARE HOME ADULTS 18-65 Church Road Respite Service Church Road Respite Service 52-54 Church Road Thornton Cleveleys Lancashire FY5 2TX Lead Inspector Mrs Ruth Edgington Unannounced Inspection 17th April 2007 09:15 Church Road Respite Service DS0000035977.V330789.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 Church Road Respite Service DS0000035977.V330789.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. Church Road Respite Service DS0000035977.V330789.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church Road Respite Service Address Church Road Respite Service 52-54 Church Road Thornton Cleveleys Lancashire FY5 2TX 01253 829373 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) Lancashire County Council Ms Elaine Jackson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Church Road Respite Service DS0000035977.V330789.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing must be provided in accordance with the residential forum guidance by April 2004. 13th December 2005 Date of last inspection Brief Description of the Service: This home is owned by Lancashire County Council and is operated by Lancashire County Social Services. It is registered with the Commission for Social Care Inspection (CSCI) to accommodate up to six adults of both sexes who have a learning disability. The home does not offer permanent accommodation, but offers a respite service for over a hundred people in the Wyre area. The home is situated in Thornton and is close to local amenities such as shops and public transport. The home was previously two semidetached houses that have been converted into one building that has two lounges, a conservatory, kitchen and three bathrooms. All bedrooms are for single accommodation and there are two bedrooms on the ground floor and four bedrooms are on the first floor, none of which have any en-suite facilities. Two bathrooms are situated on the first floor and both provide a bath with shower, whilst on the ground floor there is an assisted bathroom. There is a garden at the rear of the property that over looks a primary school playing field. The information contained in the home’s Statement of Purpose/Service User Guide is included in the information provided to prospective users of the service and their families. This written information explains the care service that is offered, who the management and staff are and what the person using the service can expect if he or she decides to stay at the home. The information is written and designed to include a picture story so that all users of the service can clearly understand the information provided. Information received on 12/03/07, prior to the visit, showed that the fees for an over night stay were £9.24. Church Road Respite Service DS0000035977.V330789.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was undertaken as part of the home’s Key Inspection. The site visit commenced at 9.15 am and took place over 3 hours. Prior to the visit the manager completed a pre-inspection questionnaire, which provided information about the people using the service, staff and other information, which assisted in assessing how the home was meeting the National Minimum Standards. Comment cards were sent out prior to the visit and in total three relatives, three people using the service and one professional person who had contact with people who stayed at the home, returned these to express their views about the service. During the visit, two of the people in the home at the time, two members of staff and the manager were spoken to individually. Also present during the visit was the member of staff who had been appointed into a management post to assist the manager in overseeing Church Road and the other home in the scheme, which is Kentmere. One of the people using the service conducted a tour of the home during the visit. As part of the visit the records of three people who use the service were looked at in detail, staff and administrative records were also looked at and discussions took place with the manager. From observations made, comments received and written documentation examined, the information has been put together to produce this report. What the service does well: This home is extremely well managed and the staff group are very committed and work together to provide a high quality service, which ensures that those using the service enjoy their stay and have all their needs met. The total inclusion of all those involved with the people using the service was very evident from the records seen and the comments made in the questionnaires received. The relaxed atmosphere in the home provides the environment in which the needs of those using the service can be easily identified and met, individually and as a group. The open and supportive relationship between everyone in the home was observed throughout the visit. One person using the service on the day of the visit readily took over the tour of the home and was very relaxed and knowledgeable about the home, staff Church Road Respite Service DS0000035977.V330789.R01.S.doc Version 5.2 Page 6 and the service provided. The staff commented later that they were amazed at the maturity of this person and would not have expected them to act in this way. The staff saw this as confirmation of far the person had progressed since coming to the home. Users of the service and their relatives are given every opportunity to voice their opinions and make suggestions about the service. From the positive comments received evidence was gained that all comments are taken on board and acted upon in order that the needs and expectations of those using the service are met. One relative commented about the staffing levels in the home being maintained to allow continuity of care and evidence was gained during the visit that the number of staff hours available had been increased to enable more time to be spent on an individual basis. Another relative stated “ Church Road is a first rate service, the management and staff are very approachable and go that extra mile to keep this respite facility at such a high standard.” A user of the service said “ I enjoy coming to Church Road” and they made it clear that they knew who to speak to if they were not happy. Staff spoken to confirmed that they enjoyed their work and felt supported by the manager. Staff training is given priority to ensure that the people who use the service are cared for by an experienced, qualified and competent work force, who can meet the different and changing needs of the service users. What has improved since the last inspection? The manager has successfully completed the Registered Managers Award, which ensures that those person using the service benefit from a well run home, which is managed by a competent and experienced person. As already stated a number of staff have increased the hours that they work , which enables the needs of individuals and the group accommodated at any one time to be met more effectively. New windows and a new front door have been fitted at the front of the home and a patio area has been developed in the back garden. Furnishings and fittings have also been upgraded since the last visit and new comfy armchairs for each bedroom were due to be delivered the week of the visit. A new television unit has been provided a lounge area and funding for the installation of an aerial point each bedroom has been given. The continual upgrading and maintenance programme in progress ensures that there is a comfortable, safe and homely environment in which to stay. Church Road Respite Service DS0000035977.V330789.R01.S.doc Version 5.2 Page 7 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. Church Road Respite Service DS0000035977.V330789.R01.S.doc Version 5.2 Page 8 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 Church Road Respite Service DS0000035977.V330789.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission and assessment procedures are clear to ensure the care needs of people using the service are identified and met. EVIDENCE: The records of people who use the service were looked at and were found to contain very comprehensive assessment information, which had been obtained before any admission took place. Evidence was included of essential information provided by relevant professionals to ensure that needs of the persons using the service were fully identified in order to provide a continuity of care. The admission process can take some time as introductory visits are made to the home to ensure that the needs of the individual can be met and enable the families to be involved. Prior to admission written confirmation that the home can meet their assessed needs is sent to them and their family and a copy of the letter is kept on their file. Staff spoken to were able to demonstrate their understanding of the individual needs of the persons using the service. Church Road Respite Service DS0000035977.V330789.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 &9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear and consistent care planning system in place, which ensures that the needs, aspirations and goals of the people using the service are met. EVIDENCE: The care files of three people who use the service, which included two people spoken to during the visit, were looked at. The detailed information seen included information about their personal, social, emotional, physical and healthcare needs. From this information an individual care plan had been put together with the involvement of the person and their family to ensure that their needs were identified and met. In the case of one person their care plan included regular visits to the home, working to an over night stay once they felt confident to do so. This had now been achieved and when spoken to during the visit they said that they enjoyed coming to the home and were observed being very relaxed and relating well to the staff, which confirmed that the time and effort put into the process had been successful in meeting this persons needs. Church Road Respite Service DS0000035977.V330789.R01.S.doc Version 5.2 Page 11 The care plans are reviewed on a regular basis and comments made by one relative indicated that they were kept informed of any issues that occur during the person’s stay and any changes that have been identified in regard to individual’s needs. The care plans show the level of support and assistance required so that staff have clear instruction as to what is needed for the benefit of the person using the service. Staff spoken to confirmed that they were involved in the care planning process and were able to demonstrate their understanding of individual needs. The records also contained clear risk assessments, which enable the staff to give the support required whilst encouraging the people who use the service to maintain their independence. The risks undertaken included basic daily living skills such as making a drink for themselves and others. Daily records are kept during the persons stay and provide a clear picture of how the needs of the individual user of the service are being met. Church Road Respite Service DS0000035977.V330789.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 excellent. This judgement has been made using available evidence including a visit to this service. Opportunities for development and community participation are addressed in the care plans ensuring that people have lifestyle that meets their individual needs and expectations. EVIDENCE: Through the discussions with the manager and staff on duty it was clear that they understood the importance of encouraging independence and promoting the personal development of the people using the service. Staff spoken to confirmed that they not only work very closely with the individual but also with the relatives in order that the needs and wishes of the person using the service were appropriately met, especially as they are only in the home for a short period of time. Examination to the care files showed they contained a list of all the dates that had been booked for the person to stay at the home. This enabled arrangements to be made to accommodate, if at all possible, people who had similar wishes and also who had formed friendships. The manager stated that Church Road Respite Service DS0000035977.V330789.R01.S.doc Version 5.2 Page 13 a number of the people using the service enjoyed going out as a group and on their last stay had gone to a local show, brought their supper back to the home and had thoroughly enjoyed the experience. A notice is displayed in the hallway showing information of what is going on in the community, so that people have the choice to be involved if they wish and they are encouraged by the staff participate, within their capabilities. Activities are arranged to meet individual wishes and abilities, so that no one feels that they are being disadvantaged. One person was very clearly making plans for the day and observed telling the staff member accompanying them, what they wanted to do and where they wanted to go and the staff member readily accepted their wishes. Through regular discussions with the people using the service and the comment cards that devised for them to complete without much difficulty, information is gained as to their wishes, expectations and needs. One person had requested a dartboard and this had been provided and the manager confirmed that they made every effort to meet individual requests. Comments made in the questionnaires completed by people using the service clearly indicated that they liked to choose what they did when they were staying at the home. One relative also confirmed that people were always approached and encouraged to voice their wishes. The menus are arranged to meet individual likes, dislikes and nutritional needs. The shopping is done locally and the provisions purchased to meet the needs of people in the home at any specific time. The manager confirmed that meals are prepared using the knowledge of each individual’s preferences, however that they are able to choose what they want when they come in as it can depend on what they had eaten whilst out at the day centre or college. A record is kept of the meals served to ensure that they are receiving a wellbalanced and varied diet. Church Road Respite Service DS0000035977.V330789.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans give clear guidance for the best way to support people so that staff assist in a manner that meets individual needs and ensures their protection. EVIDENCE: The care records examined contained very comprehensive information in regard to the persons physical and emotional needs and the amount of support required. The records provided evidence that the staff work closely with the person using the service, their family and other professional so that the specific needs of the individual are identified and met. A comment received from one professional indicated that they always received positive feedback from the family of the person using the service and found the staff to be always professional and very helpful. The staff spoken to had a good knowledge of individual’s preferences and specific medical needs, which was confirmed through examination of care records. Church Road Respite Service DS0000035977.V330789.R01.S.doc Version 5.2 Page 15 Throughout the visit observations were made of the support that was given to maximize the privacy, dignity and independence of the people using the service. One of the people in the home during the visit provided a guided tour of the home and it was very obvious from their actions that the staff ensured that the principles of privacy and dignity in the care provided were being upheld. Evidence was seen that staff had a clear understanding of the areas of equality and diversity and how this is transferred into the care provided. Examples were given of situations that staff had experience in and how these had been managed. From comments received and observations made, evidence was gained that the people using the service were receiving the personal support that they needed and there was a genuine fondness and relaxed atmosphere displayed thought the time of the visit. One relative stated that first-rate support was given, the staff were very good and it was a stable team, which led to a very relaxed atmosphere beneficial to those using the service. The medication procedures undertaken in the home ensure that medication is administered in a safe manner for the protection of the those using the service. All staff who administer medication have received training and information is kept of all the medication being administered and any side effects or additional information that staff may need. Records and the storage facilities seen were good and there was a clear audit available to ensure that the medication is managed correctly and safely for the benefit of each person. Church Road Respite Service DS0000035977.V330789.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 &23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements in place for handling complaints ensure that people feel confident that their complaints will be listened to, taken seriously and they will be protected at all times. EVIDENCE: The complaints procedures is clear and is in a format that is easy to use. The information available is pictorial and on view in the hallway of the home. This includes forms in relation to complaints, compliments and comments for users of the service and their relatives to complete if they wish. Copies are also kept in each bedroom for easy access. The service user who participated in the tour of the home clearly knew where these forms were and what they were used for and from comments received it was clear that people using the service and their relatives were aware of the procedures. One person said, “They listen to me”. Through observations and discussions during the visit evidence it was clear that staff were aware of individual behaviour changes and gestures that may indicate if a person was not happy and was not able to communicate verbally. Staff receive training in relation to safeguarding adults through the Learning Disabilities Award Framework (LDAF) and Lancashire County Councils training scheme. Church Road Respite Service DS0000035977.V330789.R01.S.doc Version 5.2 Page 17 Staff spoken to had a good understanding of the procedures to ensure that the people using the service are kept safe. There have been no complaints received by CSCI (Commission for Social Care Inspection) or external body since the last inspection. Church Road Respite Service DS0000035977.V330789.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 &30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The respite service continues to provide a homely environment for people during their stay. EVIDENCE: A tour of the home took place with one of the people using the service on that day. The home was found to be warm, clean and free from any obvious hazards. The home is an adapted property and none of the bedrooms have en suite facilities, however there are sufficient bathing and toilet facilities around the home to meet the needs of those accommodated. All the bedrooms are cheerful and have adequate storage space. They all contain a television and music centre, which the home provided. The manager confirmed that funding had been arranged to fit an aerial point in each bedroom to enable better viewing. Church Road Respite Service DS0000035977.V330789.R01.S.doc Version 5.2 Page 19 Since the last visit, new windows and doors have been fitted to the front of the home and blinds fitted around the home. Comfortable armchairs were to be delivered later in the that week and new bedding, towels pictures, cushions and furnishings have been purchased, all of which ensure that those using the home are provided with a comfortable and homely environment during their stay. The staff had identified a possible risk in relation to the ground floor bathroom and the close proximity of the laundry facilities. A full risk assessment was undertaken and appropriate steps taken to ensure the safety of staff and person being assisted in that bathroom. The garden area is pleasant and well maintained and those spoken to during the visit said that it was well used in the good weather. Examination of policies, records and information received prior to the visit confirmed that regular tests to systems and equipment are undertaken ensuring the safety and protection of all those in the home. The home has a maintenance plan, which the local authority address any issues raised through a devolved budget, to ensure that the home continues to be safe and well maintained for those being accommodated. Church Road Respite Service DS0000035977.V330789.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 excellent. This judgement has been made using available evidence including a visit to this service. The recruitment procedures and training provided for staff ensure that those using the service are protected and cared for by staff who are competent and qualified to undertake their role. EVIDENCE: There have been no new staff employed in the home since the last inspection. The records of the staff member on duty were looked at and evidence was found that confirmed that the correct recruitment procedures had been followed. This included completion of an application form, proof of identification, references and satisfactory disclosures through the CRB (Criminal Records Bureau), which all ensured that people using the service were protected. Staff who work in other local authority establishments within the scheme sometimes provides cover and information in relation to their employment is readily available. Church Road Respite Service DS0000035977.V330789.R01.S.doc Version 5.2 Page 21 Staffing levels are flexible due to the purpose of the service in order that the needs of the individuals using the service can be adequately met. One member of staff was going off duty at the time of the visit and they stated that they had no problems, enjoyed working in the home and felt supported and included in all aspects of the care provided. Comments received from staff confirmed that they worked as a team and adapt to meet the needs of the people in the home at any one time. Recently a number of staff have increased their hours to enable more individual attention to be given to those individuals who require this. Comments received from relatives prior to the visit included “ The management and staff are approachable and open to any information needed to achieve a smooth and enjoyable stay”. “The staff have a needs led approach and provide a first class service”. Training records were seen and it was confirmed that over 50 of care staff have completed an NVQ (National Vocational Qualification), which ensures that staff have the skills and competencies to provide care and support for those using the service. One member of staff who had completed NVQ level 3 was hoping to undertake some training in management as a step to further developing her knowledge and experience, which would ultimately benefit those using the service. The training needs are discussed during the staff’s individual supervision sessions and a variety of training is provided in order that the specialist needs of those who stay in the home can be met. Church Road Respite Service DS0000035977.V330789.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well managed and systems are in place for the protection of the staff and people who use the service. EVIDENCE: The manager’s leadership was very good and the staff spoken to confirmed that they felt valued in their role, which ensured that the needs of all individuals who use the service could be met. Since the previous inspection the manager has achieved the required qualifications for her post ensuring that the home is managed by a competent, qualified and experienced person for the benefit of those using the service.. The home is run in a very relaxed and flexible way and people spoken to said that they enjoyed coming to the home. Church Road Respite Service DS0000035977.V330789.R01.S.doc Version 5.2 Page 23 The health and safety of the people using the service is protected by the policies and procedures in place in the home. Evidence was seen that confirmed that staff receive mandatory training in relation to these issues. Comments received from relatives confirmed that they were satisfied with how the home was managed and the support that they received. One stated that their relative was very happy since going to Church Road and another stated that they could not fault the home in any way. There are very good systems in place for monitoring the quality of the service provided in order that any changes identified can be made for the benefit of those using the service. Regular team meetings are held to pass on relevant information and obtain the views of staff. The minutes seen showed that issues such as training, the team brief, health and safety, abuse, service user contracts and improvements to the service. Meetings are also held on a regular basis with those using the service. The meetings ask ‘What they like about the home, what they don’t like, what they like to do and what they would do to improve the service’. The comments received are taken on board and every effort is made to ensure that their wishes and expectations are met. Copies of the Fylde and Wyre Service Plan and the Annual Report by the Local Authority were displayed for people to read if they so wished. An internal audit had been undertaken in February 2007 and a copy of this report was seen. The home is visited on a very regular basis by a senior manager of the local authority and evidence was seen to confirm the positive affects of these visits in the improvements made to the home. However they was no evidence to confirm that they complete a monthly report following these visits. The manager said that she had the appropriate forms available and would ensure that in future these were completed and a copy retained in the home for inspection if required. Church Road Respite Service DS0000035977.V330789.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 4 33 x 34 3 35 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 4 14 x 15 4 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 x 4 x x 3 x Church Road Respite Service DS0000035977.V330789.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. 1 Standard YA37 Regulation 26(2)(c ) Requirement The representative of the registered provider must complete a report following their monthly unannounced visit to the home, a copy of which is to be kept in the home. Timescale for action 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Church Road Respite Service DS0000035977.V330789.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Church Road Respite Service DS0000035977.V330789.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. Re-publishing this information is in breach of the terms of use of that website. 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