Inspection on 26/03/07 for Chy Colom

This inspection was carried out on 26th March 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chy Colom 24/02/09

Chy Colom 03/03/06

Chy Colom 25/08/05

Similar services:

Clouds House

Closereach

Westcliffe House

Hilldales

Longreach

Chandos House

Cherry Orchards Camphill Community Ltd

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

CARE HOME ADULTS 18-65 Chy Colom Chy Colom Agar Road Truro Cornwall TR1 1JU Lead Inspector Ian Wright Key Unannounced Inspection 26th March 2007 09:30 Chy Colom DS0000063547.V334340.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 Chy Colom DS0000063547.V334340.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. Chy Colom DS0000063547.V334340.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chy Colom Address Chy Colom Agar Road Truro Cornwall TR1 1JU 01872 262414 01872 262355 chycolom@nddaction.org.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) Addaction Ltd Mr Roland George Bence Care Home 11 Category(ies) of Past or present alcohol dependence (11), Past or registration, with number present drug dependence (11) of places Chy Colom DS0000063547.V334340.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd March 2006 Brief Description of the Service: Chy Colom is a detached property positioned in a residential area of Truro, close to the City Centre. There is a large garden at the front of the building and some car parking space. The registered provider is Addaction, a national charity providing support for people with substance misuse (i.e. drug and alcohol) problems. The registered manager Roland Bence has worked at the home for several years. A substantial refurbishment was completed in January 2004, which significantly improved the accommodation. The home has three floors; on the ground floor there is a large lounge, a dining room, a study room and a counselling room. The home is non-smoking but there is a facility at the back of the home for those who wish to smoke. The bedrooms are on the first and second floors; four of them are shared rooms. Access to these floors is by stairs only, wheelchair users or residents unable to climb stairs cannot be accommodated at the home. The home operates a twelve-week rehabilitation programme. Residents are only accepted onto the programme following a very comprehensive assessment. Appropriately qualified and experienced staff work in the home. A copy of the inspection report is available in the home, and it is suggested a full copy of the report is requested from management or CSCI if required. The fee at the time of the inspection is £550. There are additional charges e.g. for newspapers etc. Chy Colom DS0000063547.V334340.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place in fourteen and three quarter hours over two days. All of the key standards were inspected. The methodology used for this inspection was: • To case track three service users. This included, where possible, meeting and discussing with the service users their experiences, and inspecting their records. • Discussing with staff their experiences working in the home. • Discussion with other service users. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. Other evidence gathered since the previous inspection, such as notifications received from the home (e.g. regarding any incidents which occurred), was used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? What they could do better: There are three statutory requirements. The registered persons are required to implement these requirements by law within the timescales set. Firstly, information kept in the home regarding recruitment checks on staff need to be improved. Some information, for some staff, was absent in the Chy Colom DS0000063547.V334340.R01.S.doc Version 5.2 Page 6 home. This included documentation such as an application form, reference checks and a Criminal Records Bureau check for one person. The registered manager said this information had been obtained but was possibly stored at the organisation’s other office. Where necessary, staff files need to be properly organised and the relevant information available for inspection. Secondly, some further training for some staff is required. This includes, in some cases; fire safety training, moving and handling training, medication training, infection control training, first aid training and food handling training. Training regarding the needs of people with epilepsy is also required. Thirdly staff must complete more regular checks on emergency lighting in addition to the checks performed by the fire equipment maintenance company. 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. Chy Colom DS0000063547.V334340.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 Chy Colom DS0000063547.V334340.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): 2, 5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The registered persons have developed a suitable statement of purpose and service user guide so service users can be aware of the services offered at Chy Colom. Service users are issued with a license agreement at the time of admission. Service users subsequently receive suitable information regarding their rights and responsibilities. The pre admission assessment procedure is to a high standard, and enables the registered persons to ascertain they can meet the needs of service users, before admission is arranged. Service users are encouraged to visit the home before admission so they can ascertain if the service will be suitable to meet their needs. EVIDENCE: Chy Colom has a detailed service user guide and statement of purpose and this information is available to people who stay at the home. The registered persons ensure an extremely comprehensive and thorough assessment is completed with prospective service users before admission is arranged. This includes the service user completing an application form and staff meeting with Chy Colom DS0000063547.V334340.R01.S.doc Version 5.2 Page 9 the person before admission is agreed. A copy of an assessment from the referring authority (where applicable) is also obtained. Service users the inspector spoke to all said they visited the home, before admission was arranged, and were encouraged to meet other service users, stay for lunch etc. Individual service user files all contained a copy of license agreements, and staff confirmed these were issued at the time of the service user’s admission. Service users receive a copy of Chy Colom’s ‘Welcome Pack’ when they come to stay at the home. This includes a copy of the home induction, a contract, their license agreement and a care plan. Chy Colom DS0000063547.V334340.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. All service users have a care plan and these are reviewed. Care plans ensure staff have suitable information to provide care. Addaction offers a comprehensive rehabilitation programme which enables service users to make decisions about their lives with suitable assistance as required. The registered persons approach to handling service users moneys is good so service users can be assured their finances are maintained appropriately where staff are involved in this area of their lives. The registered persons have a suitable approach to risk, so service users can be assured they will be supported to take risks as part of an independent lifestyle. EVIDENCE: Chy Colom DS0000063547.V334340.R01.S.doc Version 5.2 Page 11 A copy of a care plan is contained in each service user file. These are regularly reviewed with the service user, at least on a monthly basis, as part of individual’s programme during their stay. Service users said they had an individual key worker who met with them on a regular basis. Small amounts of service user money are kept in the office on behalf of individual service users. Storage of moneys is suitable and suitable records are kept. Service users said there is a daily meeting in the morning to discuss any issues which may arise in the household. Service users also meet with a substance misuse counsellor several times a week to assist with their personal development. Service users unanimously agreed these meetings enabled them to make decisions about home life, and to improve their own individual skills to cope with their substance misuse issues. Service users said staff work in a consultative way regarding how the home is managed. There are reasonable rules and expectations regarding participation in the recovery programme, and how communal living is conducted. Service users and staff said the recovery programme is designed to enable service users to have an improved set of skills and knowledge to come to terms with their addiction(s), and thus enable them to live without drugs or alcohol once they leave the programme. Service users who were near completion of the programme all stated the programme had assisted them to make a substantial change in their outlook on life. Service users said they were optimistic about being able to live without drugs and alcohol after they had left the programme. Some people did raise concerns that there is now less access to appropriate support before admission to the programme, and also that there is limited support and follow up once they have left the programme. However this is not the fault of Addaction or staff at the home. They are however issues which need to be addressed by wider drug and alcohol services, and the statutory authorities. The registered provider has a satisfactory policy regarding diversity and equality. There are currently no service users from ethnic minorities, although the registered provider stated the home would be more than happy to accommodate service users from other cultures. The local population is predominantly Cornish, and from ‘White-UK’ background. Women service users have equal opportunity compared with their male counterparts. Issues regarding sexuality seem to be suitably addressed. The service can only provide very limited access for people with a physical disability. For example there is not access for wheelchair users to any of the bedrooms in the home. Chy Colom DS0000063547.V334340.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): 11, 12, 13, 15, 16, 17 Quality in this outcome area is good to excellent. This judgement has been made using available evidence including a visit to this service. Addaction provides a suitable structured rehabilitation programme to enable service users to come to terms with the reasons for their addiction(s). There are appropriate opportunities for service users to go out and mix in the wider community. Service users can maintain relationships with friends and relatives while they are completing the programme. Service users rights are respected, and service users are enabled to take a suitable amount of responsibility in their daily lives. Suitable arrangements are in place so service users enjoy a healthy and varied diet. EVIDENCE: Addaction employs substance misuse counsellors who meet with individual service users several times a week to assist them with their personal development. A structured programme of group sessions also takes place each day. Staff and service users all said the programme was highly beneficial to assist personal development. The registered manager said the programme was Chy Colom DS0000063547.V334340.R01.S.doc Version 5.2 Page 13 successful in ensuring most service users did not return to substance misuse after they have left the programme. Service users and staff said that as part of the programme service users do not go out into the community on their own during the initial fortnight of the programme. Service users are however encouraged to make links with local Alcohol Anonymous and Narcotics Anonymous groups during their stay as part of their individual programmes. Support is given to enable service users to maintain contact with friends and relatives during the programme. Once people are established on the programme they can seek permission to have weekend or evening leave to return home or spend time with friends or relatives. As part of the programme rules, service users should not commence sexual relationships with each other during the programme. This seems reasonable considering the intensive personal and group work that is involved as part of the programme. Service users said there are some leisure activities available. For example there are games and a television available in the home. There is a computer room which service users can use for their study. Some group leisure activities are arranged, for example for people to go bowling. One of the staff said the home would like to obtain a minibus if they can raise the funds. One service user said they thought it would be beneficial if there was a freeview or satellite TV facility. However the manager felt this may detract from service users interaction in the evening. Another service user said they felt there should be more staff available in the evenings and at weekends to enable more group activities to take place. However it is accepted that currently there is insufficient funding available to enable this. Service users said they need to be up to commence the programme at 10am each day, but they can go to bed when they wish. Service users said staff worked with them in a way, which respects their privacy and dignity. All service users said staff were very supportive and kind. Staff were also seen as respectful of individuals’ privacy. For example staff knock on bedroom doors, and their mail is not opened without their agreement. Locks are fitted to bedroom doors. Service users and staff said service users have involvement in household tasks for example doing laundry, cleaning tasks, shopping and cooking. The building was extremely clean at the time of the inspection. Service user were observed helping with cleaning, cooking and washing up. The food provided is to a very high standard. The inspector shared meals with service users on both days of the inspection. A vegetarian meal option is available as required. In the evening, and at weekends service users prepare the food. Service users have a say in drawing up the menu. Suitable records are kept regarding food prepared. Hot and cold drinks, fruit and biscuits are available throughout the day. All service users said the food provided was to a very high standard. Chy Colom DS0000063547.V334340.R01.S.doc Version 5.2 Page 14 A cook is employed, and a service user assists each day with food preparation. The cook provides ‘home cooked’ food, and uses fresh produce wherever possible. The cook said she tries to teach the service users about a balanced healthy diet, and about working to a limited budget. The cook had a good understanding of the importance of ensuring service users eat well, particularly as many may have had a poor diet before coming to Chy Colom. Chy Colom DS0000063547.V334340.R01.S.doc Version 5.2 Page 15 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. Personal care is delivered to a good standard, and there are suitable links with medical professionals. The management of service users medicines is to a good standard so service users can be assured their medication is suitably looked after. EVIDENCE: On the whole service users do not require any personal care apart from assistance with medication. The majority of support consists of general counselling, emotional and practical support. Some service users admitted may have a diagnosis of epilepsy. Service users generally spoke highly of the support provided to them. However some service users said some staff should have been more proactive in supporting one service user, for whom the placement broke down. However the manager and staff said the person had higher needs than the team was told on assessment, service users were not left to support the person, and staff were active ‘behind the scenes’ to support the person. Chy Colom DS0000063547.V334340.R01.S.doc Version 5.2 Page 16 Staff and service users said suitable links are made with local GP’s and other health professionals to assist service users during their stay. This includes support from the mental health team and district nurses where this is required. Service users medication is stored securely. Storage is well organised, and records kept are appropriate. Most of the staff have received training from a pharmacist regarding the administration of medication, although a record of this training was not available for some of the staff (for example bank staff). If these people administer medication they must receive suitable training and the registered persons must be able to evidence this. Chy Colom DS0000063547.V334340.R01.S.doc Version 5.2 Page 17 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 is a suitable complaints procedure available to service users, and this should allow complaints to be dealt with appropriately if they are made. A satisfactory adult protection policy is in place which provides a suitable framework to protect service users if they are at risk. EVIDENCE: The registered provider has developed a complaints procedure. The manager has included a summary of this in the statement of purpose / service user guide. There has been no complaints received by the provider or by the commission. The home also has satisfactory policy and procedure regarding preventing service users from abuse. All staff have a Criminal Records Bureau (CRB) check and where appropriate a Protection of Vulnerable Adults (POVA) check. However the documentation was not available for one member of staff. Staff and service users all said they had not witnessed any bad or abusive practices. Chy Colom DS0000063547.V334340.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. Addaction provides clean, well maintained and a homely environment at Chy Colom. EVIDENCE: The building was inspected. The home offers a pleasant and homely environment for service users. The home is not accessible to wheel chair users. There is suitable heating, lighting and ventilation. Bedrooms and communal areas are of a satisfactory size to meet the needs of service users, however some of the bedrooms are shared. There is a large lounge, a separate dining room, a ‘quiet’ room, and an activity / computer room. The home is nonsmoking throughout but a facility is provided at the back of the home for those wishing to smoke. The laundry facilities are adequate for the size of the home and are situated off the garage at the back of the home. There are good hand-washing facilities for staff and protective clothing is provided. The home was clean and hygienic on the day of the inspection. Suitable cleaning routines are in place. Chy Colom DS0000063547.V334340.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is adequate to good. This judgement has been made using available evidence including a visit to this service. Staffing levels appear satisfactory so service users can be assured they will get suitable levels of staff support. Recruitment records need some improvement. Suitable recruitment procedures and records help to ensure service users know they are in safe hands. Staff induction and training needs some improvement to meet regulatory requirements. Equal opportunities issues regarding recruitment and work practices seem appropriate. EVIDENCE: Rotas indicate the registered provider provides suitable staffing to currently meet service users needs. The minimum number of staff is one person at any one time- including one person who sleeps in overnight. However therapeutic staff are also employed so there is usually at least two staff on duty, plus the manager during the working week. Service users stated they believed staffing levels were generally satisfactory. However some service users said it would be beneficial for there to be a second member of staff on duty during the evening / at weekends so there were more staff available for activities or support. However the commission recognises current staffing is satisfactory and there is limited finance available to increase staffing at present. The registered persons should note that if the needs of people being referred to the scheme do Chy Colom DS0000063547.V334340.R01.S.doc Version 5.2 Page 20 increase, staffing levels should be increased e.g. to ensure the health and safety of staff and service users. The inspector inspected staff files. The registered manager accepts that the system does need to be reviewed, although there is generally satisfactory information available as required by regulation. However for some staff some of the information was absent from files e.g. an application form, copies of references, a copy of a Criminal Records Bureau check for one person, a copy of evidence of staff induction. The registered manager said this information had been obtained but was at the organisation’s main office in Truro. This information must be available for inspection in the home. The registered persons have a generally suitable training programme. This includes fire training, first aid, food hygiene, manual handling, and infection control. Regarding meeting regulatory requirements the commission has the following comments: • Fire training. The manager is trained as a fire warden and delivers staff training. There are records to state most staff have recently received this training. However records are insufficient regarding the delivery of training for some of the auxiliary, relief and therapeutic staff. • Food handling. The cook has attended an intermediate food hygiene course. Other staff have not received basic food handling training, however the registered manager said they do not handle food. The registered persons must ensure that if staff do handle food (e.g. from making a sandwich) they must receive appropriate food hygiene training. • First Aid. Five staff have a first aid certificate, however some of the relief and therapeutic staff do not. As long as there is always a member of staff on duty who has at least an approved persons first aid certificate there is no need for further training. However, for example, if relief staff are left on duty alone (e.g. sleeping in) these staff must receive suitable training. • Manual handling. Currently no service users are admitted who have physical disabilities, although all staff must have basic manual handling training e.g. regarding moving inanimate objects. This training may be able to be delivered via video based training. The manager said some staff have received this training as part of their national vocational qualifications (NVQ) • Infection control training. The registered manager said one of the other Addaction managers delivered training last year regarding infection control. It is essential all staff receive this training. This training may for example be possible e.g. via video based training or from the NHS infection control nurse. • Medication training. Most care staff have received this, although it may be necessary that some of the therapeutic and relief staff also need to receive this training. Chy Colom DS0000063547.V334340.R01.S.doc Version 5.2 Page 21 • Epilepsy. Some staff have received training in this area. If service users are admitted with this diagnosis there must always be at least a member of staff on duty with training in this area (i.e. if the service user requires support). The community nurse may be able to provide this training. Video based training may also be suitable to provide basic awareness but it is advisable to check this with the person responsible for health and safety within Addaction, and community nurse services, whether this would be satisfactory. Some staff have also had the opportunity to attend training managing aggression, drug and alcohol awareness and health and safety. Addaction has a suitable approach to ensuring staff have the opportunity to obtain a National Vocational Qualification in care. According to the manager 50 of staff have either a NVQ 2 or 3. Chy Colom DS0000063547.V334340.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, 43 Quality in this outcome area is generally good. This judgement has been made using available evidence including a visit to this service. The home is well managed by a suitably skilled, experienced and knowledgeable manager. There is a satisfactory assurance system in place to enable service users and other stakeholders to be consulted about their views. The management of health and safety issues is generally good so service users can be assured they live in a safe environment. However emergency lighting needs to be tested more frequently by the home’s staff. EVIDENCE: Mr Roland Bence appears to be suitably experienced, knowledgeable and skilled to manage the home. Addaction has a suitable approach to quality assurance. A survey was completed in 2006 regarding stakeholder views and these were positive. The manager also arranges regular staff meetings and regular residents meetings. Chy Colom DS0000063547.V334340.R01.S.doc Version 5.2 Page 23 The registered provider has a suitable health and safety policy. Records kept of checks required by regulation are generally to a good standard. For example there are suitable records of the testing of most fire equipment, the central heating system, portable electrical appliances and the electrical hardwire circuit. Accident records are maintained. Health and safety risk assessments are satisfactory. A suitable fire risk assessment has also been completed. Suitable insurance cover appears to be in place. However emergency lighting needs to be tested by staff, at regular intervals, as recommended by the fire officer. This equipment is however tested , as is required, by the company employed to maintain the fire system, but additional visual testing needs to be implemented and evidenced. The registered persons have developed an annual development plan, and a business and financial plan as was required in the previous inspection report. Both of these documents are to a suitable standard. Chy Colom DS0000063547.V334340.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 4 3 X 4 3 5 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 4 4 X LIFESTYLES Standard No Score 11 4 12 4 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 3 Chy Colom DS0000063547.V334340.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 YA34 Regulation 19(5) Requirement Timescale for action 01/06/07 2. YA35 18(1) 3. YA42 23(4) The registered persons must ensure there is full and satisfactory information available regarding the recruitment of staff (e.g. as outlined in schedule 4.6. of the Care Homes Regulations 2002). This information must be available for inspection. The registered persons shall 01/10/07 having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that the persons employed to work at the care home receive training appropriate to the work they are to perform. (For example training required by law and some of the training appropriate for this service is outlined within the body of the report.) The registered person shall after 01/06/07 consultation with the fire authority make suitable arrangements for the testing and maintenance of all fire equipment. (For example ensure staff test emergency lighting at DS0000063547.V334340.R01.S.doc Version 5.2 Chy Colom Page 26 frequencies recommended by the fire officer). 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 Chy Colom DS0000063547.V334340.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Chy Colom DS0000063547.V334340.R01.S.doc Version 5.2 Page 28 - 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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