Inspection on 17/01/08 for Consensa Care Limited

This inspection was carried out on 17th January 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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Edenvale

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Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Consensa Care Limited 21-25 Third Avenue Manor Park London E12 6DX Lead Inspector Keith Izzard Unannounced Inspection 17th January 2008 11:00 Consensa Care Limited DS0000068975.V357838.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 Consensa Care Limited DS0000068975.V357838.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. Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Consensa Care Limited Address 21-25 Third Avenue Manor Park London E12 6DX 0208 514 5169 0208 514 5169 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) Consensa Care Ltd Elizabeth Jane Sharpe Care Home 14 Category(ies) of Learning disability (0) registration, with number of places Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 14 N/A Date of last inspection Brief Description of the Service: 21-25 Third Avenue is a purpose built 14-bedded residential unit providing support for up to 14 adults (18-65) of either sex with learning disabilities. It is owned and operated by the Consensa Care organisation that also operates several other residential homes in the area. At the time of inspection the home had four residents and the responsible person stated that all new residents would have extended introductions to the home and that it was a matter of policy that the home would not aim for full occupation at any time. The property is very well furnished and the accommodation provided is of a high standard. All service user rooms are single and have en suite facilities. The home is split into two self- contained units with a potential for seven residents to occupy each of the units that are locate on the ground and first floors. There are other communal areas within the building that allow for a range of occupational and recreational facilities such as quiet, games and private meeting rooms as a rehabilitation area including a cooking area. There is also a large court- yard area within the complex providing sports/recreational facilities for residents. The existing staff team has a good level of experience in learning disability and a good level of training is provided for care staff, all those in post either have or are undergoing NVQ level 2 or 3 training. The current fees for the home range between £1500-£3000, the higher end charges reflect the need for the high level of 1:1 or 2:1 support needs. Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means the people who use this service experience good quality outcomes. The site visit for this unannounced inspection was completed over a period of 7 hours on 17/01/08. Two members of staff and the Responsible Individual assisted with the Inspection as the Registered Manager was unfortunately off sick. All the residents were seen in the home as all four, currently accommodated were at home on the day of inspection. This was the first inspection of the service following registration February 2006. The inspection included a review of information received about the service, a tour of the premises, inspection of records, talking to and observing residents’ interaction with members of the staff team. Following the inspection contact was made with relatives and other interested parties to get their views of the service. These were all positive. A visiting senior care manager was also spoken to on one of the inspection days and he spoke highly of the service provided by the home. There was a happy and positive atmosphere in the home on the days of inspection and residents appeared well cared for by staff members who were observed to be both caring and professional in their approach with residents. In view of the communication difficulties presented, we spoke to two residents briefly. What the service does well: Pre admission assessments were well completed and excellent arrangements made for phased admissions for residents to the home. Records seen were well maintained and care plans were up to date. Care plans reflected resident needs and showed how these were to be met. Staff spoke respectfully about the residents and showed insight and knowledge into their needs. Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 6 The home had access to a mini-bus, which helped with outings and transport in general for the residents. Attention was given to ensuring the environment and equipment provided was safely maintained. All bedrooms were used for single occupancy, which afforded the residents privacy. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Consensa Care Limited DS0000068975.V357838.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 Consensa Care Limited DS0000068975.V357838.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): 1,2 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user guides need to be produced in as suitable format. Individual needs are fully assessed prior to admission and residents are able to “test drive” the home prior to making a decision to become resident. EVIDENCE: Standard 1 The home has produced a comprehensive Statement of Purposed that fully meets this Standard. However, a Service User Guide in a suitable format for residents is still in preparation and a requirement is therefore made that this be completed as soon as possible. See Requirement 1 Standard 2 We viewed the two most recent admission assessments in residents’ care plans, and these were very detailed, and showed that sufficient information was recorded before a decision was made to offer a placement to the resident. The assessments indicated that information was taken in regards to different aspects of daily living, communication needs, and social preferences, and Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 10 included health needs and evidence of assessing compatibility with other service users. Standard 4 From the records available the Inspector was able to evidence that prospective service users are given the opportunity to “test drive” the home prior to moving in. In one instance an extended introductory phase had been arranged including all daily meetings over a two-week period being conducted by the appointed key worker. It was noted that a potentially very difficult transition from family home to Third Avenue had been achieved with positive outcomes for this resident. All the other residents had also received extended transition periods to facilitate smooth admissions to their new home. This is commendable practice. Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 11 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. Service users benefit from individual plans and risk assessments and are supported to make their own decisions. EVIDENCE: Standard 6 Two care files and individual plans were examined in respect of service users. Individual plans were comprehensive and involved service users and their representatives, including family or advocates and other professionals involved. These plans are regularly reviewed with outcomes clearly stated and agreed by all participants, although given the short time the home has been open it was only possible to ascertain that individual care plans were scheduled for, at minimum, six monthly reviews. In practice reviews had been held at a much higher frequency in the early months of residents admission. The two records seen of residents case tracked were comprehensive in content and up to date. Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 12 Standard 7 Care provided for two residents was tracked through care plans and other documents such as daily diaries and the communication book used by staff members. Interaction between staff and residents, observed by the on the day of inspection demonstrated choice being encouraged by staff members in relation to the activities that residents were engaging in. Evidence was available from the service user’s records examined that residents are both encouraged and enabled to express choice in what they do and staff record these occasions in the daily diaries of individual residents. The level of communication difficulties of some service users is such that staff members would find it very difficult to meaningfully engage service users in participating in the running of the home and contribute to policies and procedures, however, please see Standard 39. See Requirement 4 Two staff members interviewed said they endeavoured to involve residents in decision making based on their individual communication and comprehension. This is inevitably restricted by the severe communication difficulties of some of the residents and depends heavily on staff interpretation and historical knowledge of residents likes and dislikes. Staff members were observed communicating with residents and involving them in whatever was going on in a professional and caring manner. Standard 9 Risk assessments were undertaken with resident involvement and records showed clearly how risks were to be managed by staff members. They had been updated on a regular basis and in response to any new risks identified, updated risk assessments are readily accessible for all staff members including newer staff who might be less familiar with service user’s needs. Any restrictions placed are few and would be for the safety and welfare of service users, for example not leaving the home unaccompanied. The home has a policy and procedure for unexplained absences and it was noted that this includes guidance for staff on the steps to take when a service user is identified as missing and for when they return. Up to date photographs of residents were available to assist this process. Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 13 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): 12-17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are resident led and the approach to them from staff members is both relaxed and empowering to the residents. Residents receive a varied and nutritional diet. EVIDENCE: Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 14 Standards 12-14 None of the residents has been assessed as being able to sustain full time employment and none attend local day centres. In any event, the philosophy of the home is to utilise community facilities without recourse to day centres unless this is specifically required within the placing authority contract. Evidence was available from the care files of residents that were seen, that opportunities are being made available for the personal development of residents. An activities folder records what activities are provided for individual service users. Evidence was available that a good range of fulfilling activities and outings are provided from the care and activities records examined. The home has established contact with a local college and a leisure centre. Some service users attend arts and crafts activities and music and aroma- therapy sessions. Other activities include in house keep fit, gym sessions, confidence building, body awareness, and visits to places of interest on a to one to one basis with key workers. Standard 15 Staff members actively support and encourage family contact but one resident has restricted contact, the subject of multidisciplinary agreement and the home has made a referral for independent advocacy but without success currently. Through the various activities and outings provided residents are provided with some opportunity for meeting with other people outside of the home, however, staff report that there are no relationships of significance for any of the residents other than their family. Appropriate risk assessments were identified in respect of expressed sexuality or vulnerability in this area, in respect of all three individual care files that were examined. Standard 16 Residents were enabled to choose their own clothes and hairstyles, when accompanied by staff members on shopping tips. Residents were also supported to choose their own decoration and personal items for their own rooms and to participate, or otherwise in activities of their own choosing. During the course of the inspection we observed that staff talk to and interact with service users and that service users choose, for themselves when to be alone or in company. Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 15 Standard 17 Varied and nutritious meals were provided to meet resident preferences and a rota of meals that ha been provided over a period of four weeks was seen that showed this and a good supply of both fresh and frozen food was seen stored in the home. Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 16 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. Residents receive personal care in the way they prefer and their physical health needs are met. Medicines were mostly assessed as safely managed on the day of inspection but two areas of managing the system require improvement. EVIDENCE: Standard 18 All bedrooms in the home are single occupancy, which provides privacy for the residents. Care plans seen showed how personal care needs were to be met. In view of the extent of residents’ communication difficulties it was only possible for one resident to comment that their needs were met in a way that suited the individual. Similarly, most of the residents in the home were unable to give feedback about any aspect of the service because of communication difficulties. Daily records were kept to show the care provided and activities the residents were involved with. Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 17 All residents were registered with a GP and staff supported them to access other medical services such as dental and optical care. Regular links were maintained with the local community learning disability team to support staff with meeting resident needs. Standard 19 Care plans and daily records showed how personal care was provided. Staff interviewed spoke with knowledge and confidence about resident’s individual needs and preferences. Residents were supported to access health services appropriately and these were provided either in the home or by attendance at local clinics and surgeries. Evidence was available from care files and daily diaries in respect of service users that a wide range of health and related professionals are commissioned to attend to health needs on a regular basis, for example: Diabetes Clinic, Physiotherapist Psychologist Psychiatrist Speech and Language Therapists, Psychiatrist and Dietician. One resident received regular visits from a District Nurse in order to give him Insulin. Other medical investigations were taking place in response to episodes of challenging behaviour exhibited that were being monitored by a Consultant Psychiatrist, who was in regular contact, monitoring and advising staff members on how best to provide care and support for the resident. Any general nursing care needs would be commissioned via the GP from the local District Nursing service or Community Psychiatric Nurse. All service users require considerable assistance with their personal care needs and the home operates a same gender care policy, where possible, in relation to male service users, and strictly in relation to female service users, although none were resident at the time. On the day of inspection service users appeared adequately and tidily dressed in age appropriate clothing. Personal appearance had been attended to and staff were observed to be sensitive and respectful to service users. Standard 20 We saw the homes medication policy; this includes guidance on the administration, storage and disposal of medication and the use of “as required (PRN)” medication. The policy addresses self-medication and identifies the need for this to occur within a risk assessment framework. Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 18 The system for medication was then examined and was generally well managed. The current list of medication received is recorded on a front sheet alongside a photo of the resident. None of the residents are able to deal with their own medication and all staff members who deal with it are trained to do so and the training is recorded. MAR sheets were examined and recorded appropriately and tallied with the blister packs that were retained in a lockable cabinet. However it was noted that a handwritten entry on a MAR sheet had not been countersigned. This must occur, in order to avoid potential mistakes being made that could be avoided by two people independently checking the entry. See Requirement 2 External medication was stored separately. Checking in and any returns of medication was well organised. However, it is recommended that all liquid medicines and creams used are dated when they are opened to assist in monitoring proper storage. See Recommendation 1 Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 19 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. Adequate procedures were in place to ensure complaints were appropriately managed and to ensure protection for residents. EVIDENCE: Standard 22 The home had policies and procedures in relation to complaint management. A system was in place to record complaints made about the service. At the time of the inspection four complaints had been received by the home, none had been made to the Commission. We were satisfied that all had been dealt with appropriately by the manager and responded to within the required times-scale. A pictorial complaints leaflet has been provided to assist any residents with communication difficulties, and will also be incorporated within the new Service user Guide when this is finalised. Standard 23 Staff members had received training on adult protection and those interviewed, displayed a good understanding and an awareness of this area including whistle- blowing procedures. Any suspicions or allegations of abuse, or unexplained injuries to residents would be referred to the London Borough Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 20 of Newham Community Learning disability team for investigation and to the Commission via Regulation 37 notifications. One such referral had been made since the home had opened and we were satisfied that the correct procedures had been followed, immediately, and that the welfare of residents within the home had not been compromised. The matter had been fully considered by the Newham Safeguarding Adults Team and the result of their consideration was that a false allegation had been made. This outcome was verified by an examination of the relevant records retained within the home that we were shown. Accidents records relating to both residents and staff members were also seen and were well maintained and appropriately recorded and followed up by staff members in respect of residents. Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 21 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. Residents live in a safe environment. The home was clean and hygienic throughout. EVIDENCE: Standard 24 All areas of the home seen were clean, tidy and free of unpleasant odours. Bedrooms were nicely personalised and the home was suitable to meet the needs of the residents. Standard 30 On the days of inspection the home was clean, bright and airy and free from offensive odours throughout. Systems are in place to prevent the spread of infection. Overall, it was noted that the laundry area was satisfactory, although Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 22 very cramped, with adequate equipment for dealing with soiled articles. Domestic cleaning materials are stored in a locked cupboard and COSH procedures are readily available for staff members performing domestic tasks. Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the homes recruitment practises and benefit from well supported, trained and supervised staff. EVIDENCE: Standard 32 Training records for three staff members were seen and this showed that a good level of training had been provided and was being planned for the future. Induction training had been provided for all new staff and foundation training following this. The home has already achieved the required minimum of 50 trained to NVQ Level 2. From observations made of care worker practice and the evidence of training provided, there was a good level of skills and experience and those staff observed had the requisite attitudes and characteristics necessary to adequately support service users. Staff members were observed to be respectful and caring in the way they were relating to service users. It was equally evident that service users were content within their environment and Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 24 responding positively to any staff interventions to assist them when engaging in activities. Standard 34 We viewed the homes recruitment policy and procedure and noted that this complies with National Minimum Standards. Personnel records including details of pre employment checks are held at a centralised personnel office. A sheet containing a summary of this information was available on site for inspection. This evidenced that the home obtains two references and proofs of identity prior to employment commencing. The reference numbers for Criminal Records Bureau (CRB) checks were also available, Overall, three personnel files were examined for staff recruited and recruitment practice was found to be in accordance with the requirements of Regulation 19 and Schedule 2 of the National Minimum Standards. Standard 35 Training records for individual staff members were seen and this showed that a good level of training had been provided and was being planned for the future. Induction training had been provided for new staff and foundation training following this. Overall, a comprehensive spread of training had been provided for staff members and included mandatory annual updates in fire training. However, all staff need training in moving and handling, that is mandatory, and must also be updated annually. See Requirement 3 Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 25 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 good. This judgement has been made using available evidence including a visit to this service. Residents all benefit from a well run home. Surveys of residents’, relatives’ and professionals’ views on the running of the home must be publicly available and residents meetings introduced as soon as practicable. The health and welfare of residents users are promoted and protected EVIDENCE: Standard 37 Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 26 The Registered Manager is experienced and has the necessary NVQ4 qualification. Staff members interviewed stated that she is approachable and supportive and would not hesitate to discuss any concerns about the home or the welfare of residents with her. Communication within the home was of a good standard with team meetings held regularly and the manager, overall, complies with the requirements of Standard 37. The manager has undertaken training in order to update her own skills and knowledge. Standard 39 Regulation 26 reports are regularly completed on a monthly basis, as required and copies sent to the CSCI. The Responsible Person advised that home is developing a service user and other stakeholder feedback questionnaires as part of its quality assurance process. These have yet to be finalised or distributed, but the home plans to carry out this exercise and publish the outcomes in the current year. This must be done. See Standard 7 See Requirement 4 Standard 42 A number of records to do with safety and maintenance were seen by the Inspector and were found to be up to date and well recorded. The manager confirmed that all staff had annually updated fire training. In respect of other checks the implementation of fire drills, alarm tests and checking of fire prevention equipment was recorded and up to date. A recommendation made at the previous inspection that the fire risk assessment for the building should be reviewed was complied with. Evidence, was available in the records retained that routine servicing and testing had taken place on the electric, gas and water systems and corresponded with the information provided by the manager in the Pre Inspection Questionnaire. Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 27 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 2 2 3 3 X 4 4 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 34 35 36 3 3 X 3 X LIFESTYLES Standard No Score 11 12 13 14 15 16 17 X 3 3 3 3 3 3 X 3 2 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000068975.V357838.R01.S.doc Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Consensa Care Limited Score 3 3 2 X 3 X 2 X X 3 X Version 5.2 Page 28 N/A 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 YA1 Regulation 4& Schedule 1 Requirement The Registered Person must ensure that an updated Service user Guide is produced in an appropriate form for service users with communication difficulties. Handwritten entries on MAR sheets must be checked and countersigned by a second member of staff. All staff must receive mandatory training in moving and handling. The Registered Person must ensure that surveys of the views of residents, their relatives, advocates and involved professionals regarding the quality of the service provided are conducted annually and available for reference. Regular service user meetings must be set up as soon as possible. Timescale for action 01/05/08 2 YA20 13 01/03/08 3 4 YA35 YA39 YA7 18 24 01/05/08 01/06/08 Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA20 Good Practice Recommendations Liquid medicines and creams should be dated when they are opened, to assist monitoring of use. Consensa Care Limited DS0000068975.V357838.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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