Inspection on 11/01/06 for Cloverdale

This inspection was carried out on 11th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cloverdale 02/08/06

Cloverdale 03/05/05

Cloverdale 29/11/04

Cloverdale 08/06/04

Cloverdale 19/05/03

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Cloverdale 95 Anstey Lane Alton Hampshire GU34 2NJ Lead Inspector Mrs Pat Hibberd Unannounced Inspection 11th January 2006 09:00 Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 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 Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 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. Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cloverdale Address 95 Anstey Lane Alton Hampshire GU34 2NJ 01420 544118 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) ILIACE Limited Miss Charlotte Louise Farr Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 2005 Brief Description of the Service: Cloverdale was registered in May 2000 and is one of a number of Homes owned by Iliace Limited. It is situated in a rural location close to the town of Alton with its range of leisure and shopping facilities. The Home has four bedrooms, a large lounge/diner and a kitchen and laundry area. There is a garden to the rear of the property and a large driveway with provision for both the Home and visitor’s cars. Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over three hours and was the second unannounced inspection of the 2005/-2006-inspection programme. The inspector focussed on care provided to service users, discussions with staff, inspection of files and other documentation relevant to this inspection. Sixteen standards were assessed on this occasion. Five areas of improvement were identified. All of the core standards for younger adults have now been inspected during the 2005/2006inspection year. The inspection included a tour of the home. Discussions were held with the Home’s manager and one permanent staff member. Time was spent with two service users with a view to gaining an understanding of care provided and to observe staff interaction and support as detailed in care plans. Two service users’ files were viewed and their care provided by the Home in all areas of their life assessed and discussed with both the manager and staff. What the service does well: What was evident throughout the inspection was the commitment to ensuring service users are central to all care provided and lead a full and positive life style. The home has a communication co-ordinator who is responsible for ensuring the methods of communication in the home are appropriate for each individual. The home is keen to ensure service users’ interests are identified and both in house and community activities are provided. The Organisation has their own “activities (DAP) team” who, alongside the management and staff, assess and provide individual programmes for all service users. There is a range of training provided and staff confirmed that they receive regular supervision and daily support from the manager, which they find beneficial to their daily practice. Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: There were five areas of service provision that required improvement three of which were immediate requirements. The first related to the need for the manager to undertake a fire evacuation with all staff to ensure they are clear as to their role and responsibilities in such an event. A risk assessment relating to the building must also be available for inspection. Both of these areas of improvement are brought forward from the last inspection and requirements made on this occasion. A requirement brought forward from the last inspection relates to the reporting of any incident to the commission, which affects the well being of service users accommodated. Two further areas identified included a risk assessment being completed in greater depth for one service user in relation to the access to knives in the kitchen. The carpet on the stairs is in need of replacing due to a large tear on Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 Page 7 the landing that has been highlighted to the Organisation by the manager as a health and safety issue. 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. Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 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 Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 There is a comprehensive assessment process ensuring service user’s needs are identified by the Home prior to admission. EVIDENCE: The Home has an extremely comprehensive process of assessment that includes four areas of need. The first is a personal profile of the individual, the second skills maintenance, the third work placements and finally behavioural guidelines. There has been one new admission since the last inspection with a service user moving into the Home in October 2005. From discussions held with the manager, the individuals key worker and documentation viewed it was evident that the service user had been involved in the process with contributions from family and professionals to ensure the Home can meet the individual’s needs. Views could not be obtained from the individual, as they were not at Home during the inspection. Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Service users are encouraged to make choices about their daily life within a risk management framework. The arrangements for care planning are generally consistent for all service users ensuring their care needs are met. EVIDENCE: At the last inspection two care plans viewed did not determine whether service users were receiving the appropriate level of support due to risks relating to their care needs not being updated. The manager alongside individuals’ key workers has addressed this. During this inspection two files were viewed all of which contained individual care plans, community programmes and details of personal support needs and approaches to be taken in the event of incidents which “challenge” the service. Reviews had been held. Plans detailed assessed needs and action required to meet those needs. With the exception of one area of service provision which required further detail risk assessments were up to date in both service users’ files confirming Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 Page 11 that they are being supported to achieve their potential within a risk management framework. One staff member explained that if a new risk is identified the assessment would be written by a key worker and the manager or in conjunction with the staff team. The assessment would always be shared with all staff through documenting the changes in the communication book held in the office and the duty handover sheet of which all staff including agency staff are required to read at the commencement of their shift. The manager was asked what action she would take to ensure risks are minimized at the same time ensuring service users could partake in their chosen lifestyle. An example was given and a risk assessment viewed of one service user cooking in the kitchen. The risk assessment had been compiled in conjunction with staff and the individual. However, when viewing one incident form relating to the same service user it was evident that there was a potential risk when they had access to knives. It was agreed with the manager that the risk assessment would be reviewed that day, amended as appropriate and shared with all staff. The manager and one staff member indicated that not all service users would have a concept of what a care plan was or, that one was held in a file detailing their care needs. However, both were able to demonstrate how service users made choices through an understanding of language used, objects of reference, pictures and Makaton sign language or signing specific to an individual of which details would be held in their care plan. For example if a service users care plan indicated that they would be going horse riding the manager indicated that they would show the individual clothing required for the activity. The service user would express through facial expression or behaviour as to whether they were happy to participate in the activity. Both the manager and one staff member were observed offering service users choice and providing care in a dignified and valuing manner throughout the inspection. All service users have a key worker who is responsible for ensuring care plans are kept up to date and, that changes are communicated with all relevant personnel. Service users are always invited to reviews but due to individual needs, staff indicated that they might only participate for part of the meeting. Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,15 and 16 Service users have opportunities to be a part of the local community, maintain friendships and family relationships with rights and responsibilities upheld in their daily lives. EVIDENCE: The Organisation has an ‘activities ‘ team and together with the home staff they endeavour to ensure service user’s have a community presence by devising programmes of activities within a risk management framework of care. These include cooking, shopping, craft, swimming and a number of community based activities. However, the manager indicated that due to sickness during the latter part of last year the activities team had cancelled a number of activities resulting in some service users being very upset even though an alternative in house activity would always be offered. One service user spoken to indicated that their interests are pursued through planned programmes and include trips to the theatre, college and shopping. Discussion regarding cancelled activities could not be held with service users due to the potential distress this could cause. The Home has a Communication Coordinator who the manager explained has developed in house programmes, which are compiled in both pictorial formats Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 Page 13 and through objects of reference to ensure service users can identify how they are to spend their day. There was information available in the Home in pictorial formats as to local activities available in the community to enable service users to have knowledge and choices. Rotas confirmed that there are two staff on duty during the evening and weekends to support activities identified with the manager and one staff member indicating that they considered the staff complement to be appropriate. They did however; consider the Home would benefit from further drivers, as there is not always a driver on duty that can result in activities being cancelled. There is shortly to be a vacancy in the staff team with the manager indicating that the advert requests the successful applicant can drive. The Home has one unmarked vehicle with taxis and buses also used as a means of transport. The manager indicated that the majority of service users accommodated would have limited understanding of the concept of voting although all receive voting cards. The manager confirmed that this would be pursued if appropriate for an individual. Service users are supported to maintain family links and friendships with all visitors welcome to the Home with the individual’s agreement. Visitors can meet with service users in their bedroom or communal areas of the Home if they so choose. The Home has a visitor’s policy and procedure which requests that visitors telephone the Home prior to visiting to ensure their relative/friend is at Home. Records completed by key workers indicated that service users are supported to meet relatives/friends and, that the contact is welcome by service users. The Home has a policy and procedure with regards to sexuality and relationships of which one staff member confirmed they were aware of. Daily routines in the Home enable service users to have choices, maintain their independence and individuality of which the manager and one staff member were able to give a number of examples. These included service user’s being addressed by their preferred name, personal care being offered in a respectful and dignified manner and, at a time suited to the individual and service users having unrestricted access to all parts of the Home with the exception of other service users’ bedrooms. Throughout the inspection staff were observed providing the care described, with service users indicating through their behaviour or gesture that they felt well supported by staff and had positive relationships with staff. Service users are supported to undertake household tasks if they so wish. There are no service users who smoke with staff being required to smoke outside if they wish to do so. Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Personal support is provided in a manner that meets service users needs and preferences. EVIDENCE: Two care plans viewed indicated that personal care /support needs had been assessed with details of service users preferences as to how the care should be provided. Occupational therapists and the community health team provide support and guidance to the Home as needed. Observations of staff support to service users was dignified, respectful and ensuring privacy. An examples being of staff supporting a service user who was feeling distressed with the support being offered without drawing attention to the individual. Service users can choose what they wear, hairstyles and when they want to get up and have a bath. In discussion with one service user they described where they had been during the morning and how they had been supported by staff to prepare for the day. It was evident that choices were being offered and appropriate support given to enable service users to make an informed choice in a number of areas of their lives. Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 Page 15 The standard relating to medication was not fully inspected on this occasion as all areas of the standard were inspected in May 2005. However, one area requiring improvement was followed up. This related to the need for care plans to include guidance to staff with regards to when they are required to administer PRN (as required) medication. From two care plans /guidelines viewed this work has been completed. In discussion with one staff member they were able to describe their understanding of the guidelines and their application to service delivery. Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Arrangements for protecting service users are satisfactory although reporting procedures still require some improvement. EVIDENCE: The Home has a copy of the Department of Health No Secrets document and the Hampshire Adult Protection policy and procedure. All staff have undertaken Adult Protection training and in discussion with one staff member they demonstrated an understanding of their responsibilities. The manager indicated that she had also received adult protection training, had read the Hampshire Adult Protection policy and procedure and was aware of her role in the event of an allegation of abuse. One staff member indicated that they felt well supported by the manager and were receiving guidance as to how to manage behaviours exhibited by service users that “challenge” their practice/service delivery. All staff has undertaken restraint training (SCIP) that is provided by the Organisation’s Training manager. At the last inspection there were three areas of service provision requiring improvement. The first related to guidelines being written as to approach’s to be taken or, when restraint should be used being documented in individual service users’ files. This requirement has been met. A second area related to allegations of abuse being reported to Social Services. The manager indicated that there have been no allegations or incidents of abuse of which incident records/care plans viewed supported. However, a third requirement relating to the manager ensuring the commission are notified of any event which adversely affects the well being or safety of any service user has not. This was evident following one incident report read which involved a service user hitting another service user several times. Whilst the Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 Page 17 incident had been recorded the commission had not been notified as required under Regulation 37. Whilst records indicated that the incident had only occurred on one occasion there had also been further incidents where the same service user had experienced hair pulling by other service users in the Home. It was agreed with the manager that a meeting would be called with the staff team with a view to compiling a strategy/risk assessment to satisfactorily manage and monitor the situation. The views of the individual could not be ascertained on this occasion. Service users money/records were inspected with the manager with documentation indicating that the records were up to date and that systems in place were satisfactory. Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The Home is generally homely and comfortable although some improvement is required. The home has satisfactory practices ensuring that service users live in a clean and hygienic environment. EVIDENCE: Cloverdale is double- glazed throughout and has an enclosed rear garden. The home has a large lounge/dining room and a spacious kitchen with separate laundry room. There is a bathroom on the ground floor and separate toilet and bathroom facilities on the first floor. Since the last inspection the drive has been improved and the lounge has had some new curtains. The home has various hi-fi, television and video equipment Each service user has a single bedroom, which they have personalised with their own possessions and electrical equipment. One service user invited the inspector into their room that was personalised and comfortable. The service user indicated that they were happy with the environment although there was limited opportunity for discussion due to their individual needs. The laundry room is situated next to the kitchen with policies and procedures in place to ensure washing is not taken through the kitchen at a time food is being prepared to prevent infection. Control of Substances Hazardous to Health Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 Page 19 assessments [COSHH] policies and procedures are in place, to ensure that staff and service user’s health and safety is promoted. A staff member was observed wearing protective gloves whilst working in the kitchen area. The Organisation has their own maintenance team. The manager indicated that there is a planned maintenance and renewal programme for the Home. However, the stair carpet was seen to have a tear on the landing. Whilst the manager indicated that this has been raised as a health and safety issue for several months and quotes obtained for a replacement confirmation is awaited from the operational manager as to whether it can be replaced. It was agreed that the manager would contact the operational manager for the Organisation that day to confirm that the new carpet can be ordered. In the interim the tear has been secured with tape and staff and service users advised by the manager of the risks. There have been no visits undertaken by the statutory fire officer or environmental health department since the last inspection. Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 34 The home’s recruitment practices are satisfactory, ensuring service users are protected. Service users benefit from competent and qualified staff. EVIDENCE: Throughout the inspection the manager and staff member were observed as interested, motivated and committed to the needs of service users in the Home. They were observed communicating effectively with individuals and demonstrated knowledge and understanding of strategies in place to deal with anticipated behaviours of some service users that may have a negative impact on others. Recruitment practices are thorough with all applicants undertaking a CRB (Criminal Record Bureau) check, having to provide two written references and complete a satisfactory three month probationary period before being con firmed in post. Service users are fully involved in the recruitment procedures. For example prior to an applicant being offered a post they would meet with service users in the Home as part of the recruitment process. Service users views/interaction would be observed and contribute to a decision as to whether the applicant is offered a position in the Home. The standard relating to training was not fully inspected having been inspected during the last inspection in May 2005. However, one area of improvement Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 Page 21 was followed up relating to all staff receiving moving and handling, food hygiene, adult protection and health and safety training. This has been met. One staff member indicated that she felt the training to meet her needs and welcomed additional training provided in house by the manager. Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 There is an effective manager who ensures service users views contribute to all developments of the Home and service provided. Health and safety is generally satisfactory although there are some improvements required. EVIDENCE: The manager Miss Farr has been in post since October 2004. Miss Farr has worked alongside adults with learning disabilities for a number of years. Miss Farr has recently completed her Registered Managers Award and has undertaken further training that includes moving and handling/ fire safety/ and adult protection. Miss Farr has a range of responsibilities and indicated that these are reflected in her job description and include ensuring the written aims and objectives of the Home are met, policies and procedures are implemented, the budget is properly managed and service users are aware of their terms and conditions of residency. Miss Farr indicated that she felt well supported by her line manager and received regular supervision. Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 Page 23 From discussions held with one staff member and one service user and, from documentation viewed Miss Farr is demonstrating her ability to ensure systems are in place to achieve and meet her role and responsibilities and, provide effective leadership and management of the Home. Service users were seen to respond positively to the manager who was able to demonstrate throughout the inspection her understanding and knowledge of service users’ needs. The Home has an annual development plan with objectives in place to measure outcomes for service users in respect of their care; staff and environment .The objectives are linked to the Organisations overarching objectives. Two objectives recently met relate to the appointment of a communication coordinator in the Home and the commencement of service user meetings The views of service users could not be ascertained due to there having only been one meeting held which had highlighted issues regarding engaging all service users in the process. This will be followed up at the next inspection. Further systems implemented to ensure there is an effective quality assurance and monitoring of service users’ views include care plan and risk assessment evaluations on a two monthly basis – or sooner if required and monthly visits undertaken by senior managers of which copies of the outcome of those visits are forward to the commission. Staff meetings are also held regularly of which one staff member indicated are of much benefit for sharing information and ideas. Policies and procedures are reviewed by the manager in conjunction with senior members of the organisation. The standard relating to health and safety was not fully assessed as it was inspected at the last inspection. However, three areas of improvement identified at the last inspection were followed up. The first related to the need for the manager to undertake a fire evacuation with all staff to ensure they are clear as to their role and responsibilities in such an event. This has not been undertaken. In discussion with one staff member they were able to describe what action they would take should there be a fire in the Home. However, the manager indicated that she is aware that the “evacuation “ had been agreed to be undertaken at the last inspection and would ensure it was carried out within the next week. A requirement was made to this effect on this occasion. A risk assessment relating to the building was also agreed at the last inspection to be available in the Home for inspection. The documentation was once again not available in the Home. The manager further said she was not aware as to when the assessment was carried out. A requirement was made on this occasion for the assessment to be held in the Home and for the manager to ensure she is fully involved in the process. Staff must be aware of the outcome of the assessment and implications for service delivery. A requirement relating to the manager ensuring there is a system in place in the Home to ensure the safe storage of food has been met. Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 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 X 23 3 ENVIRONMENT Standard No Score 24 2 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 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X X 3 X 3 X X 2 X Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 Page 25 YES 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 YA9 Regulation 12 Requirement The Registered providers must ensure a risk assessment is undertaken with regards to one service user using knives whilst undertaking activities in the kitchen or other areas of the Home. This must be kept under review. The Registered providers must ensure the carpet on the landing is replaced as highlighted as a health and safety issue by the manager. The Registered Providers must ensure a risk assessment is undertaken of the environment, available for inspection and shared with all staff. This must be kept under review. The Registered providers must ensure all staff are aware of their role and responsibilities in the event of a fire evacuation in the Home. The Registered Providers must ensure the Commission are notified of any event that adversely affects the well-being or safety of any Service User. (This requirement was made at DS0000011907.V275390.R01.S.doc Timescale for action 11/01/06 2. YA24 13 11/01/06 3. YA42 13 25/01/06 4. YA42 13 18/01/06 5. YA23 37 11/01/05 Cloverdale Version 5.1 Page 26 the last inspection with a timescale of 3/5/2005) 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 Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 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 Cloverdale DS0000011907.V275390.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!