Inspection on 16/02/06 for Cumberland Avenue Residential Home

This inspection was carried out on 16th February 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cumberland Avenue Residential... 06/10/08

Cumberland Avenue Residential... 06/12/06

Cumberland Avenue Residential... 14/07/05

Cumberland Avenue Residential... 31/01/05

Cumberland Avenue Residential... 11/08/04

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

CARE HOME ADULTS 18-65 Cumberland Avenue Residential Home 31 Cumberland Avenue Bury St Edmunds Suffolk IP32 6TG Lead Inspector Deborah Seddon Unannounced Inspection 16th February 2006 10:00 Cumberland Avenue Residential Home DS0000024369.V283239.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 Cumberland Avenue Residential Home DS0000024369.V283239.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. Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cumberland Avenue Residential Home Address 31 Cumberland Avenue Bury St Edmunds Suffolk IP32 6TG 01284 725972 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) H4037@mencap.org.uk Royal Mencap Society Mrs Caroline Joyce Smith Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th July 2005 Brief Description of the Service: 31, Cumberland Avenue is a six-bedded care home for adults with learning disabilities. It is located in a residential part of Bury St. Edmunds and is situated in a quiet road with access to green areas nearby. The home is close to local shopping facilities and a short car or bus journey from the centre of Bury St. Edmunds and all the resources offered there. The home consists of a large purpose built house, which is leased from Suffolk Housing Association by Mencap who provide the staffing and administration. The home was first registered in 1994 and provides spacious and modern accommodation for the residents. Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was spread over two days starting with an unannounced visit on the 16th February on a weekday afternoon and early evening lasting four hours. The inspector was unable to access staff files as the manager was on a day off and arranged to return to the home on the 21st February to meet with the manager and inspect staff files. The inspection focused on looking at the standards not assessed at the last inspection on the 14th July 2005. Therefore to have a true reflection of the home this report should be read in conjunction with the report from the July inspection. A number of records were examined including those relating to residents, staff, training and policies and procedures. Time was spent talking with all six residents, the manager and three staff. The inspector was shown around the home and was invited by residents to see their individual bedrooms. What the service does well: What has improved since the last inspection? What they could do better: The home’s statement of purpose and service user guide needs to be updated to reflect that a resident diagnosed with dementia is living in the home and how this may impact on the other residents and prospective residents moving into the home. The manager will also need to demonstrate that staff have received training for supporting people with dementia. Although it was acknowledged at the inspection that a new staff member had a Criminal Records Bureau (CRB) taken up prior to starting work at the home, two other files looked at did not have proof of CRB being sought prior to the staff starting work at the home. The manager must make sure that all staff employed in the home have a current CRB held on file, if the CRB is destroyed a copy of the disclosure number must be held as an audit trail and proof of the CRB having been obtained prior to the member of staff commencing employment. Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 6 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. Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 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 Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5, Prospective residents can expect to have detailed information about the home before making a decision about where they live. However this needs to be updated to reflect that a resident with a diagnosis of dementia is living in the home. EVIDENCE: The statement of purpose and service user guide is well presented and offers a lot of detailed information for prospective residents. There is an established group of residents’ living at the home, there have been no new admissions to the home, and therefore it was not possible to fully inspect standards 2, 3, and 4. A member of staff informed the inspector that one of the residents has recently been diagnosed with Alzheimer’s. Cumberland Avenue is not currently registered for people with dementia and would need to make an application for a variation to the registration should they admit any new residents into the home with dementia. As the resident is already living in the home the Statement of Purpose and Service User Guide will need to demonstrate that a person with dementia is living in the home outlining the impact this may have on prospective residents and existing residents. The manager will need to demonstrate that the staff team receive training in dementia care and are able to continue to meet the needs of the resident. The resident’s care plan is regularly reviewed and updated to reflect changes in their needs. Evidence was seen that contracts and a licence agreement between residents and Mencap and Suffolk Housing Association had been signed and dated. Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 9 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): 6,10, Residents can expect to have care plan’s that identify their changing needs and support required including risk assessments which support them to lead a positive and fulfilling lifestyle. Information held about residents is accessible on request to protect the confidentiality of the other residents. EVIDENCE: The care of one resident was tracked. Each resident has a person centred plan, current file and support plan. All contributed to a detailed assessment identifying the resident’s health, personal and social needs and the level of support they required to enable them to maintain and improve their independence. The resident had limited mobility and used a wheelchair to move around. Evidence was seen that they had a mobility plan in place supported by a physiotherapy programme, which had been updated in January this year. A photographic section “about me” provided information about the resident’s likes and dislikes, what they could do for themselves and their method of communication. Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 10 Aims and objectives have been agreed with the resident and evidence was seen throughout the care plan and during the inspection that they are being supported to meet these. One objective was for the resident to be involved in the redecoration of their bedroom. The resident had spent time with their key worker discussing their choice of colours; the resident had chosen black. The support plan demonstrated that although the key worker had acknowledged the residents choice, they had encouraged them to choose an alternative colour and explained why black would be unsuitable for their room. The resident agreed and chose an alternative colour and new furniture. The residents’ are encouraged to participate in the day-to-day running of the home. They have a domestic duty plan displayed on the wall in the dining room in a picture format to remind them of their responsibilities. One of the residents was observed washing the kitchen floor and another loaded the dishwasher following supper. Another resident was being supported to prepare their lunchbox for the next day. Evidence was seen that residents are supported to manage their own finances. Details were seen on one resident’s care plan that they had an Independent Savings Account (ISA). They receive interest on money whilst still being able to have access to cash. They hold a cash card with safeguards in place agreed with the resident, the home and the bank for all transactions. A member of staff accompanies the resident to the bank and prior authorisation is needed from the home’s manager before staff can undertake any transactions. These transactions can only be made at the branch and the debit card has been rendered useless for use in cash dispensers. A mini statement is issued after each transaction. Evidence was seen that detailed records of expenditure and receipts are kept. Each of the residents have detailed risk assessments in place to minimise identified risks when undertaking daily routines such as using public transport, domestic tasks and preparing meals. For example a resident informed the inspector they were going shopping on Saturday. A support plan will be discussed with the resident and the member of staff assisting them to support the activity with minimum risks involved. Evidence was seen that risk assessments were being reviewed on a regular basis. The resident’s plans seen were accurate, up to date and kept in the staff office. Resident’s can have access to their plans but on request to ensure information of the other residents is kept private. Staff have recently been on person centred planning training and are in the process of re writing care plans with the residents to include the residents point of view. Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 11 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): 11,12,13,14,15,16,17, Residents can expect that they will be supported to have appropriate and fulfilling job opportunities and to mix with other adults in appropriate activities within the local community. EVIDENCE: The residents were observed returning home after spending the day at various placements offering day care facilities or opportunities for work. One resident informed the inspector that they had recently started doing voluntary work at an information bar, which is like a drop in centre for people with learning difficulties. They were also starting a new project working with services to business packing envelopes and compact discs. Another resident told the inspector that they worked at the Bury St Edmunds resource centre doing reception work. One residents care plan showed that they made use of daytime opportunities at the Bury resource centre. Review notes in January 2005 had an agreed programme of activities for the resident to attend five days a week. Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 12 Planned activities available include information technology (IT) communication, indoor sports, pot black, loud and proud, cookery and physiotherapy, hobbies, signing to enhance communication skills, sensory visit and cookery. The resident had obtained a community education certificate of achievement towards independence in November 2005 for physical help in the preparation of meals and cookery and a Suffolk County Council “Communication through Music”. Another resident had attended a day care service called Woodenstuff, which is a unit in Bury St Edmunds where residents are supported to make items and paint. The resident showed the inspector a compact disc (CD) holder they had made for all their Daniel O Donnell CD’s. Residents are supported to attend activities of their choice within the local community. One resident attends the Freeway club held on the first Thursday of the month. A programme of events throughout the year range from boat trips, trip to Felixstowe and a visit to Snetterton Sunday Market. Residents talked about outings and holidays that they had been on last year. One resident had had a holiday at a centre called Rainbow in Sheringham, which has been especially adapted to cater for people with disabilities. They have planned to go twice this year, in June and at Christmas. The resident has limited communication but was able to express their excitement about the holiday. A resident informed the inspector they had spent short breaks in Hunstanton for a “Turkey and Tinsel” weekend and to see Buddy Holly and the Crickets. Photographs displayed around the dining room promoted discussion about events that residents had taken part in. A resident who liked Cliff Richard and Elvis went to see an Elvis impersonator at the Ipswich Regent theatre. Another resident said they had seen ShowWaddy Waddy and Blondie also at the Regent theatre. Evidence was seen on a resident’s care plan that they are supported to be politically active with a postal vote acknowledgement seen for the 31st January 2006. Residents were observed spending time in the evening engaged in activities of their choice. A resident showed the inspector their knitting; they were making squares for a patchwork blanket for their bed. Another resident was seen enjoying doing puzzles, drawing and colouring. Staff told the inspector that residents are supported to maintain relationships by telephone and visits to and from their families. Evidence was seen by speaking with residents about their families and friends and through the many family photographs, postcards and letters around the home and in resident’s rooms that contact is maintained. The inspector was invited to join the residents and staff whilst they were eating their evening meal. Residents and staff were engaged in general conversation about the day’s events and were keen to tell the inspector what they had been doing. Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 13 The food seen was home cooked, appealing, wholesome and nicely presented and consisted of burgers, tomato and green salads with mashed potatoes. Most of the homes food is purchased on line from a local supermarket, although residents still like to go shopping to buy additional items. Cumberland Avenue Residential Home DS0000024369.V283239.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): EVIDENCE: These standards were assessed at the last inspection and were found to be met with no shortfalls. Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 15 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 Staff have received appropriate training to protect people living in the home from abuse or neglect. EVIDENCE: A requirement from the previous inspection in July 2005 was for staff to have adult protection training. Evidence was seen at this inspection that training took place on the 6th January 2006. A new member of staff spoken with has attended a two day training course protect, respect and respond, supported by written exercises for adult protection in the Mencap induction and foundation workbooks. Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 16 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): 24,25,26,27,30, Residents can expect to live in a home that meets their needs in a safe and welcoming homely atmosphere, which provides a good range of personal and communal space. EVIDENCE: The home is purpose built consisting of six bedrooms with a large open plan communal living area comprising of dining area, lounge and kitchen leading through into a conservatory. There is a separate utility room. All corridors are wide to facilitate a wheelchair user living in the home. There are five bedrooms on the first floor and one on the ground floor with wheelchair access with an en-suite bathroom. The bedrooms are fitted with wardrobes, lockable cupboard and washbasin. All areas of the home are nicely decorated, in bright and cheery colours providing residents with a homely environment. The home is kept clean and tidy and has no unpleasant odours. Residents were happy to show the inspector around the home and invited them into their individual rooms. Rooms were nicely decorated and reflected their personalities. One resident had pictures and photos of Elvis, another had posters, bedding and curtains of their favourite football team. They also had a framed Ipswich T-shirt signed by the members of the team and photographs of themselves at Ipswich football club enjoying the football. Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 17 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): 31,32,34,35,36, Resident’s can expect to be cared for by a staff team who are supported and available in sufficient numbers to meet their needs. However residents cannot expect to be protected by the home’s recruitment procedures. EVIDENCE: A member of staff discussed their job description and role of support worker with the inspector. They were very clear about their role and the aims of the organisation, stating, “staff work to support the individual needs of residents, to provide options and choices and promote independence” They were aware of the General Social Care Council and that all care workers will eventually be registered. They were also aware that staff could be struck off the register if their conduct is brought into question and found to be a risk of working with vulnerable adults. Another member of staff spoken with joined Mencap as a relief worker. They cover a lot of shifts at Cumberland Avenue and have got to know the residents well. They started their National Vocational Qualification (NVQ) level 2 in care in January 2006. They were scheduled to meet with their assessor on the day of the inspection to assess some of their work. They have completed their first module and are currently completing reflective accounts for further modules. The member of staff told the inspector they were keen to learn and was enjoying the NVQ as it makes them reflect on their practice. Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 18 The inspector was able to meet with the assessor, a former employee at Cumberland Avenue who knows the residents and staff well. They completed their Assessor Award through West Suffolk College and have signed on two staff from Cumberland Avenue as their first candidates. A recommendation at the last inspection for the manager to create an individual training profile has been implemented. A schedule of training for each member of staff with supporting certificates was seen covering a range of training including fire safety, care of medicines, induction and foundation programmes, people moving people, protecting vulnerable adults at risk of abuse, emergency first aid, food hygiene and person centred planning. A requirement was made for staff to attend mandatory training for manual handling; all staff attended a moving and handling training session in May 2005. First aid certificates have expired and require refresher training. A new employee’s records show that they are booked to attend first aid, moving and handling and adult protection training. The new member of staff was on duty on the second day of the inspection and talked with the inspector of their experience working at the home. They confirmed that they had already attended the protect, respect and respond training and that they had worked alongside an experienced member of staff for 6-7 shifts, today was there first rostered shift. Generally they felt they were getting on well with the residents and felt supported by the manager and other staff. Two members of staff are on duty at all times when residents are at home. Staff spoken with felt that two staff are adequate to meet the needs of the residents. The rota is used as a working document and reflects the actual hours, additional hours, holiday’s and off days of the staff. One resident had been supported to attend an ear, nose and throat (ENT) clinic, the additional hours were seen recorded on the rota as an audit trail of staff hours. Staff spoken with told the inspector that they receive regular supervision. This was confirmed with evidence of recorded supervision and a contract of agreement between manager and staff available on staff files. Supervision and probationary records provided evidence that work performance was discussed and evaluated, how the member of staff was meeting objectives, personal and professional development and their experiences and expectations. However, records show that supervision of staff does not meet the recommended minimum of six sessions per year. There was evidence that regular staff meetings take place with the next meeting scheduled for 3rd March. The minutes of the last meeting in January seen identified that issues relative to the running of the home and residents were discussed. Three staff files were inspected. Only one had a criminal records bureau check (CRB) taken up prior to commencing employment. The manager explained that a Protection of Vulnerable Adults (POVA) first check had been undertaken, however the written conformation of the POVA fist was destroyed when the CRB clearance was received. The file relating to the second member of staff showed that they have worked at the home for a long time and any previous Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 19 documentation supporting the staffs CRB was destroyed when the update was received. Residents are encouraged to take part in the recruitment process. Interviews for staff were taking place on the second day of the inspection. However all the residents had declined to take part in the interviews as they had prior engagements. The residents had already had the opportunity to meet the potential employees as they had been invited to the home as part of the interview process to see how they engaged with the residents. Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 20 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): 37,38,39,40,41,42, Residents can except to live in a home that is effectively managed and is run in their best interests by an experienced management and supported staff team. However, the records in the home must be available and open to inspection at all times to safe guard the residents interests and welfare. EVIDENCE: Cumberland Avenue has a scheme manager and a deputy manager, both were on a day off on the day of the inspection. However the inspector did meet with the manager on the second part of the inspection. The manager is working towards the National Vocational Qualification (NVQ) Level 4 in management and the deputy has twenty-one years experience working with Mencap. The training file showed that both the manager and deputy attend training to up date their knowledge and skills to manage the home. The manager demonstrated a good knowledge of the residents and staff. The staff and residents spoke well of the manager and felt they were approachable, supportive and very patient. Staff felt that the manager led by example and that they were part of the team. Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 21 Following the last inspection Mencap have devised a live action plan on how the home is to achieve higher scores. The standards are listed with detailed information on how the home is to meet the standard and what they need to do to achieve an improved score. All staff have been involved and have read the action plan. A requirement was made at the previous inspection for the home’s policies and procedures to be available at all times for residents and staff to refer to should they need them. The manager had had the files at home to help them with the National Vocational Qualification (NVQ) studies and has retuned them to the home. The staff files were not accessible for inspection as they are kept locked in the staff office and only accessible by either the Manager or Deputy Manager. Another requirement from the last inspection was for the manager to forward a copy of a risk assessment to the Commission for Social Care inspection (CSCI) for a resident dependent on a wheelchair and the action to be taken to minimise the risk of death or serious injury in the event of a fire. A copy of the risk assessment was received which gives clear guidelines on the risks and actions to be taken. The Commission for Social Care Inspection (CSCI) certificate of registration was correct and displayed in the entrance hall. Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 22 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 X 3 X 4 X 5 3 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 3 25 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 3 3 3 3 3 X Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 (Sch 1) 5 Requirement The statement of purpose and service user guide must reflect that a resident diagnosed with dementia is living in the home and the impact this may have on existing residents and prospective residents and that staff receive appropriate training to support a person diagnosed with dementia. All staff employed in the home must have a current CRB held on file, if the CRB is destroyed a copy of the disclosure number must be held as an audit trail and proof of compliance with the requirements of schedule 2. Timescale for action 31/03/06 2. YA34 19 (4) (b) Sch 2 (7) 19/02/06 Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 24 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 YA36 Good Practice Recommendations Staff should have recorded supervision at least six times a year in addition to the regular contact on day-to-day practice. Cumberland Avenue Residential Home DS0000024369.V283239.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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. 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