Inspection on 13/12/06 for Derwent House

This inspection was carried out on 13th December 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Derwent House 01/06/07

Derwent House 17/02/06

Derwent House 29/03/05

Derwent House 03/08/04

Derwent House 14/01/04

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

CARE HOME ADULTS 18-65 Derwent House 206/8 Lightwood Road Longton Stoke-on-Trent Staffordshire ST3 4JZ Lead Inspector Mrs Mandy Brassington Key Unannounced Inspection 13 December 2006 9:45 Derwent House DS0000008222.V321292.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 Derwent House DS0000008222.V321292.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. Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Derwent House Address 206/8 Lightwood Road Longton Stoke-on-Trent Staffordshire ST3 4JZ 01782 599844 01782 318281 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) Mr Alan John Bradshaw Mrs J Bradshaw Mrs Joy Bradshaw Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2006 Brief Description of the Service: Derwent House is a registered Care Home that provides a service for fourteen adults of both genders who have a learning disability. The home is located in Stoke On Trent, Staffordshire and is accessible via public transport and is in close proximity to local amenities. The property consists of two large mature semi-detached houses. The exterior of the properties remain as two houses, in keeping with the local community. The interior structure had been designed to allow access through both buildings on two floors. The home provides ten single occupancy and two shared bedrooms, of which are located over the three floors. There is no passenger lift or specialist aids or adaptations available and these are not currently required for the service users living in the home. Three bedrooms are equipped with an en suite, with the remaining bedrooms having a washbasin. Two toilets are located on the ground floor, one bathroom and a shower room is situated on the first floor. The property also provides a dinning area, a separate lounge, two kitchens and a small laundry. Service users have access to two gardens located at the rear of the property. Limited parking is available at the front of the building. Staffing is provided on a twenty-four basis. The home provides support on a twenty-four basis to support individuals to live a socially inclusive lifestyle and develop necessary skills for independent living. Following assessment of risk, individuals are able to access community services and facilities independently and take the lead role in their care. The Manager informed the Commission for Social Care Inspection on 20 December 2006 that the fee level for the home is between £325 and £337 per week. Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was an unannounced key inspection and therefore covered all of the core standards. The inspection took place over 6.5 hours by one inspector who used the National Minimum Standards for Younger Adults as the basis for the inspection. A tour of the home was undertaken. On the day of the inspection, the home was accommodating nineteen people. Prior to the inspection visit, survey information has been obtained from individuals and their relatives. Ten comment cards were received back from service users, four from relatives and two from health and social care professionals. A Random Inspection was conducted on 4 July 2006 and addressed previous requirements and included an inspection of Activities, the Environment, Medication, Food, and Health and Safety. Some details of this inspection are included in this report. The inspection included an examination of records, indirect observation, discussions with six service users, the manager, the deputy manager, and two staff on duty. Case tracking of four care plans was undertaken. Three staff records were examined and observation of daily events took place. A discussion took place with a relative during the inspection. The Medication storage system and medication procedures were inspected. Lunch was eaten with the service users. Three requirements and two recommendations were made as a result of this visit. Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The manager and the team of staff have demonstrated a positive attitude towards the requirements made within the previous Key inspection and have met all the requirements and developed the service accordingly. The plans of care have been reviewed to incorporate the principles of person centred planning and individuals have been able to take an active role in the implementation and review of plans. Staff have ensured that service users are involved in the daily management of the home and evidence of consultation and decisions made have been recorded and signed by service users. The manager has discussed the changing needs of individuals in relation to ageing and possible changes in needs. Service users are aware of the limitations of the home, especially in relation to adaptations for people with a physical disability. Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 7 As part of the Quality Assurance Monitoring System, the manager has sought the views of individuals in relation to the home, staff, daily activities and opportunities. The exterior of the home has been decorated and service users bedrooms have been decorated to reflect individual interests. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Derwent House DS0000008222.V321292.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 Derwent House DS0000008222.V321292.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, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have a copy of the Service Users Guide and are aware of their terms and conditions of occupancy. EVIDENCE: The home has reviewed the Statement of Purpose and Service Users Guide to incorporate all areas as required in the National Minimum Standards and Regulations. One Individual reported he had received a copy, and a copy is available within the home. There have been no new admissions to the home since the last inspection and inspection of care records demonstrated individuals had received an initial assessment, and documentation was in line standard practice at the time of admission. Four plans of care were inspected and each person had an up to date contract that detailed Terms and Conditions of occupancy. Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Plans of care record up to date information regarding daily activities and areas of risk. EVIDENCE: A sample of four plans of care were inspected, including three service users resident in the home on the day of the inspection. The deputy manager reported that following the previous inspection, the plans had been reviewed to incorporate detailed records of daily activities and areas of risk, health, personal, and social care needs. There was evidence to show service users were involved with the plan and had signed the documents and records of discussion. Plans of care recorded specific objectives, support required with independence and detailed assessment of risk for community participation. During this inspection and the previous random inspection individuals were able to explain Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 11 the procedure when going out alone and if they were to return home late and how to be safe in the community, and to communicate with the home. It is pleasing to the Commission that service users are able to safely access the community independently, and the home has ensured appropriate care planning and support has been given to ensure service users are not placed in vulnerable situations. The plans contain a ‘Challenge planner’. The challenge planner records one task that the service user would like to prioritise. It is recorded in an easy read format and suitable for the needs of the individuals within the home. The topics include, what I can do already, what else will I do, who will help me and what I need. This is reviewed on a monthly basis as part of the overall review of care. Discussion with staff revealed that they consider the plans of care easy to use and they contain sufficient information to safely support individuals. Service users files are kept in a locked office for reasons of confidentiality. Discussion with service users revealed that they are able to have access to their files and often choose to be present when these are completed. The manager has consulted individuals regarding future needs and how the home is able to respond to individuals changing needs. Individuals reported that they were able to make decisions about their life for areas such as, choosing meals, activities, liaisons with family and personal finances, and are supported encouraged to take responsible risks. Staff members confirmed this. Plans of care record whether service users wish to have a suitable lock with a key to their bedroom door. Where individuals have chosen to have a lock, they have a key to their room. Individuals have recorded that as the home is staffed on a twenty-four hour basis, they do not wish to have a key to the front door. This is kept under review. Service users meetings take place bi-monthly, or more frequently if required. A record of minutes is recorded. Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users lead a socially inclusive lifestyle and are able to have access to a wide variety of leisure activities and work placements. EVIDENCE: The home is managed to support individuals to have a socially inclusive lifestyle and where possible to take the lead role in their own care. Discussion with staff and services users revealed that individuals have access to a wide variety of work and educational placements. On the day of the inspection, only six service users were resident in the home as other individuals were involved with work and college placements. Staff reported that these included working for a family’s gardening business, tree felling and gardening, College Placements, Working at a Local Stable and farm Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 13 and attending Performing Arts. Due to the restructuring of Day Services and access to College Placements, the home had reviewed the activities provided during the day. One individual reported he worked at a local Supermarket two days a week and attends a College, where he participates in craft activities, literacy and Independent Living skills. Service users reported that many individuals were visiting home and family members over the Christmas period. During the week before Christmas, individuals have three parties planned at various venues and a Christmas meal before individuals leave to visit the family home. Earlier in the month, the manager had organised a large Christmas Party at a local Community Centre for service users and for two other homes owned by the Proprietors. Friends and family were invited and service users spoke positively regarding the event. The night before the inspection, service users had attended and participated in a concert, organised by the Performing Arts Group that many of the individuals attend. Individuals stated the concert had a musical theme and individuals had played musical instruments, sound language songs, sang Christmas Carols and performed dances. The week before the inspection service users had chosen to go to the Regent Theatre and watched ‘Grease’. During the summer, individuals were able to choose a holiday. Individuals went to Brittany or a Woodside chalet in Derbyshire. Individuals spoke positively about the holiday. Comments from service user regarding the lifestyle and the home during the inspection and from comment cards included; ‘This summer I went on holiday in France with the home.’ ‘I am happy living here, I can do what I want, when I want.’ ‘I go to work, youth club, and the pub.’ ‘I choose my own meals and clean and look after my own bedroom.’ ‘I’m able to go shopping in my own and see my mates.’ Service users stated they are able to receive visitors on a flexible basis and able to spend time at the family home. There are no restrictions on visiting. During the inspection, discussion took place with one family member who confirmed visiting is flexible and her daughter is able to spend time at the family home. On the day of the inspection, the meal served at lunchtime consisted of soup and rolls or sandwiches. Service users reported that there is a choice of meals and the main meal is served in the evening. Service users participate with the shopping, and meal preparation. Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported and helped to be independent and responsible for their own personal hygiene and personal care. EVIDENCE: Plans of care recorded the level of support each individual required; many individuals are independent in relation to personal care but require prompts to ensure care and daily tasks are carried out. Discussion with one service user revealed he had lost three stone on the recommendation of a Doctor due to having a high cholesterol level. Staff had supported the individual with his diet and a record of weight loss had been maintained. The service user was pleased with his progress and stated that he planned to continue with the current diet. It was pleasing to hear the individual was aware of what constituted a healthy diet, what should be eaten and how this impacted on his health. Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 15 The plans of care recorded individual’s health needs, details of appointments and outcomes. The home uses the Monitored Dosage System (MDS) and medication is dispensed by a pharmacy into weekly cassettes. Inspection of Medication and Medication Administration Records (MAR) were satisfactory. Inspection of topical preparations revealed that one cream was being stored in a locked cupboard in the office; directions were to store within a fridge. The deputy manager made arrangements to dispose of this medication, as the manufacturer advises that the active ingredients are compromised at higher temperatures. The cream is to be kept securely in the fridge. Two service users are responsible for administering their medication. A plan of care and assessment of competency is carried out prior to individuals selfmedicating. It is recommended that the person administering the week’s supply of medication to the service user record this on the Medication Administration Record Sheet. One service user is responsible for administering Insulin. Staff reported this is stored in a locked tin in a second fridge and the service user has the key. The minimum and maximum temperature is to be recorded to ensure the medication’s viability is not compromised through storage at a low temperature below 2 degrees. A local pharmacist reviews the medication system. Each service user had a Homely remedies sheet signed by the G.P. recording what may be administered. The deputy manager reported that staff had received training to safely administer and that only staff that had received the training were responsible for medication administration. Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have access to a complaints procedure and are aware of how to make a complaint and confident concerns will be addressed. EVIDENCE: Service users reported that they keep a small amount of personal money and other monies and valuables are kept securely in the home. Individuals have a personal bank account. Three personal accounts were inspected and accounts had been appropriately maintained. Service users were aware of how to make a complaint and had a copy of the procedure. All service users spoken with reported that if they had any concerns the manager would address these promptly. Staff have access to the Vulnerable Adults Procedure and Whistle Blowing Procedure. Discussion with staff revealed that the home has not had to instigate the Vulnerable Adults Procedure and agreed that they would benefit from further training. Discussion with the manager revealed this is planned as part of the training package that has been purchased. Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 17 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, 25, 27, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to personalise their rooms to reflect their individual’s interests. EVIDENCE: The home consists of two large mature semi-detached properties, the exterior design had been maintained, to present as two houses in keeping with the local community. The interior structure had been designed to allow access through both buildings on two floors. The exterior of the home has been recently painted and has improved the overall look of the property. The home provided ten single occupancy and two shared bedrooms located on three floors. Three bedrooms were equipped with an en suite, with the remaining bedrooms having a washbasin. All rooms inspected contained a good amount of personal furniture, personal electrical equipment and were Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 18 individually decorated to reflect the personal preferences of the individuals. Three individuals reported that they recently been able to change rooms and during the summer, bedrooms had been decorated. All service users spoken with reported they had been able to choose the colour scheme. Three individuals reported that they are responsible for their rooms in terms of ensuring it remains clean and tidy. Staff are available to support individuals. It was observed that individuals had varying degrees of acceptable levels of tidiness; it was pleasing to note that individual’s preferences for the style of their room is accepted. Two bedrooms are shared rooms. A record of a positive choice to share had been recorded in the plan of care. Discussion took place with two individuals who shared a room. The individuals stated they had shared a room since moving to the home and wanted this to continue. From observation, it was clear that the two individuals had developed a close relationship and were content with the current arrangements. Plans of care recorded whether service users had requested a key to their room. Toilet and bathing facilities were available on all floors and contained appropriate equipment to meet infection control standards. The property also provided a dinning area, a separate lounge of which was equipped with essential furnishings. Two kitchens and a small laundry were also provided. Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels reflect the needs of the service users, and rotas are flexible to fit around the lifestyles of individuals. EVIDENCE: The home’s shifts are flexible to suit the needs of the service users, though are generally across three day shifts, with a minimum of two staff on duty. At night, there is one waking night staff and a sleep in person who also covers the adjacent building. On the day of the inspection, the Deputy Manager and one support worker were on duty in the morning and the Manager, a Senior Carer and support worker were on duty in the afternoon. The handover times are flexible according to the needs of the service users and planned activities in the home. The home has a good recruitment procedure that ensures that staff are suitable to work with vulnerable people. A sample of three staff files were examined and demonstrated that thorough pre employment checks are carried out. Criminal Records checks had been undertaken in all instances, and there Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 20 was proof of identity, two references and a completed application form on file. There has been one new member of staff since the previous inspection and the records demonstrated the manager had reviewed the interview practices, and recorded the interview questions and responses. Staff received formal supervision monthly with the manager. The manager reported that the home is committed to developing the skills of the staff team and all staff are working towards or have an NVQ Qualification. The manager discussed a new training package that has been purchased to ensure all staff receive the required training. The manager and deputy have received training to support and assess the staff, and to ensure individuals have gained sufficient knowledge and are competent. An external verifier will audit completed training. This will be inspected on the next visit. From discussion with the staff team and observation of practices, it was evident that staff are enthusiastic and committed to providing a good service. Staff commented that they work well as a team with good communication. Service users spoke positively about the staff team and from observation, relationships were relaxed and open. Service users and relatives comments regarding the staff included: ‘The staff are very good.’ ‘The staff are always there to speak to me if I have a complaint.’ ‘We are confident and happy about the care.’ ‘My son is looked after in an exceptional way. He is happy and safe.’ ‘Staff are pleasant and Joy [the Registered Manager] is always available.’ Comments received from one professional person involved with the home reported: ‘Staff are friendly reliable, professional and well trained.’ Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 21 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. The Manager is competent to run the home and works to continuously improve services and provide an increased quality of life for individuals. EVIDENCE: The Manager is also the proprietor, and it was evident through discussion and observation that the manager has developed strong relationships and links to the home and service users, and is committed to improving the facilities and the service provided. Staff commented they feel valued and part of a supportive team. Staff stated they would have no hesitation approaching the manager who is supportive and addresses any concerns. Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 22 The health, safety and welfare of staff and service users were protected. The registered manager had ensured that all maintenance work, repairs, annual checks, testing of equipment and regular fire drills are undertaken. Required checks have included: Annual Gas Safety Test was conducted in April 2006. An Electrical Inspection of the Fire Alarm System was conducted in June 2006. Portable appliance tests were carried out in September 2006. The home has environmental assessments of risk for each room and included, radiators, infection control, use of electrical equipment and moving provisions and goods. The manager has completed a Fire Risk Assessment and has included the dependency levels and needs of service users. There is an Emergency Contingency Plan linked to the assessment. The home conducts Annual Satisfaction Surveys. Individuals are able to comment a variety of issues including, the home in general, the environment, meals, staff attitudes and respect, access to health care, and holidays. Two individuals stated that if areas of concern are identified changes have been made in the home. Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 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 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 3 LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 X 3 X X 3 X Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 24 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 2 Standard YA20 YA20 Regulation 13 (2) 13 (2) Requirement To store a named topical cream within secure conditions in the fridge. Record maximum and minimum temperature of the Fridge where medication is stored on a daily basis. Staff to receive training in relation to the Vulnerable Adults Procedure Timescale for action 14/12/06 14/12/06 3 YA23 18 (1)(c)(i) 13/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA20 YA20 Good Practice Recommendations To purchase a separate medication fridge Record staff responsible for administering weeks supply of medication to those who self-administer on the MAR Sheet. Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Derwent House DS0000008222.V321292.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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