Inspection on 14/11/06 for Duxbury House

This inspection was carried out on 14th November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Duxbury House 10/01/06

Duxbury House 26/04/05

Duxbury House 06/01/05

Duxbury House 22/06/04

Duxbury House 20/01/04

Duxbury House 08/09/03

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

CARE HOME ADULTS 18-65 Duxbury House 38 Sherbourne Road Blackpool Lancashire FY1 2PW Lead Inspector Pauline Caulfield Unannounced Inspection 14th and 16th November 2006 10:30 Duxbury House DS0000009789.V314827.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 Duxbury House DS0000009789.V314827.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. Duxbury House DS0000009789.V314827.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Duxbury House Address 38 Sherbourne Road Blackpool Lancashire FY1 2PW 01253 440242 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 Vincent Fitzgerald Miss Tiffany Webster Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places Duxbury House DS0000009789.V314827.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may accommodate up to a maximum of 6 people with a learning disability, and when not utilising these places may accommodate up 6 persons with mental disorder. 10th January 2006 Date of last inspection Brief Description of the Service: Duxbury House provides care to six adults who have a learning disability and/or mental health problems. The property is a terraced house situated in the North Shore area of Blackpool, close to the sea front and local amenities. All service-users are provided with single accommodation, There are six single bedrooms. These are not en-suite. There is a communal lounge and dining area and a large paved area at the rear of the property. There is a Statement of Purpose/Service User Guide, which is given to all prospective residents. This written information explains the care service that is offered, who the owners and staff are, and what the resident can expect if he or she decides to live at the home. Information received prior to this visit (12/10/06) showed that the fees for care at the home are from £286 to £464 per week, with added expenses for hairdressing, chiropody, newspapers, outings and holidays. Duxbury House DS0000009789.V314827.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit, which commenced mid morning on one day and with a short visit on another day for a total of six hours. The manager completed a pre-inspection questionnaire and two comments cards were received from residents. The owner/manager and one care staff were spoken to. The inspection involved case tracking two residents as a means of assessing some of the National Minimum Standards. This process allows the inspectors to focus on a small group of people living at the home. All records relating to these people are inspected along with the rooms they occupy in the home. They are invited to discuss their experience of the home with the inspector, however this is not to the exclusion of other people living at the home. Four residents were spoken to. Conversation with residents was very much dependent on their wishes to speak to the Inspector. A tour of the home was carried out and a selection of staff, residents and administrative records were examined. From the observations made, comments received and written documentation seen, the information has been put together to form this report. What the service does well: This is a care home where people are looked after well. There is a good admission process with frequent visits so everyone can get to know each other before moving in. There is a competent and enthusiastic staff team who understand the needs of the people living there. One resident said, “, I couldn’t believe it when I got here. It is better than anywhere else”. Each resident has a detailed plan of care that is followed by staff. It is regularly checked and changing needs are recorded as they occur. Residents are involved in developing their plans and have agreed to these. Residents’ are encouraged to make decisions take responsible, well informed risks and avoid high-risk actions. Residents attend a variety of different activities as they wish, with support if needed. One resident said, “All the staff are nice and I go out sometimes with Vince. We have a good time”. Duxbury House DS0000009789.V314827.R01.S.doc Version 5.2 Page 6 Mealtimes are relaxed and flexible. One resident said, “The food is good here” Another resident said “I have no complaints’ about the home”. With another adding, “Yes it’s good here I can’t fault them I can’t complain about anything here. They are very good” Medication procedures and administration are well managed ensuring that residents receive their medication as prescribed. The home is clean throughout and smells fresh and clean. One resident said, “I have my own room it is nice”. Staff were seen chatting in a friendly way with residents. One resident said, “Staff are easy to chat to.” Another resident added,” I want to move on in a while and be more independent but it is good here. Vincent is great and all the staff here are good, all very kind”. Staff recruitment is safe and thorough and makes sure that residents are protected. Staff training is very good and helps meet residents needs and protect the health and welfare of residents, relatives and staff. The home has good checks on the quality of the home and all residents, relatives and staff contribute to this process. What has improved since the last inspection? What they could do better: Although the home has good fire safety checks, regular training for residents and staff, and all staff are knowledgeable about what to do in the event of a fire, there is no written fire risk assessment. One needs to be formulated for the home. The home has recently had an electrical check. Some remedial work is needed Mr Fitzgerald has arranged for this to be done a few days after the visit. Page 7 1st Para under what they could do better and page 22 2nd Para …. Suggest replacing ‘and there must be’ with a full stop and one needs to be formulated for the home. Please contact the provider for advice of actions taken in response to this inspection. Duxbury House DS0000009789.V314827.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Duxbury House DS0000009789.V314827.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 Duxbury House DS0000009789.V314827.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 & 5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives have the information needed to choose a home, which will meet their needs. Residents are assessed and their needs met effectively through the admission and assessment process. Prospective residents are encouraged to visit the home frequently before admission to assist them in their decision on whether they want to move there. EVIDENCE: Three residents were case tracked through the admission process, as well as talking to the manager to discuss the admission process to the home. Prospective residents usually have a long detailed introduction to the home. This is personalised to meet the individuals’ needs. They initially visit, usually with a social worker and chat and look around the home. If it appears that they may ‘like the home, the owner/manager encourages them to go away and decide whether they would like to consider living there. If he feels that the home cannot meet their needs or that they are not compatible with other residents he advises that the home cannot meet their needs. If the prospective resident decides they are interested in living at Duxbury House, the manager arranges several short tea visits, followed by several overnight and weekend stays, with longer visits after this if useful. All residents have an assessment prior to admission, which is carefully considered during the admission process. In an emergency admission Duxbury House DS0000009789.V314827.R01.S.doc Version 5.2 Page 10 situation the manager ensured that adequate assessment information was made available to him. Prospective residents are not rushed into a decision about staying in the home and on the infrequent occasion where someone’s needs are different or more complex than assessments suggests, the owner/manager works hard to ensure that all residents needs are met with the minimum of distress or disruption, while looking to move the individual to a more suitable environment. The owner/manager, Mr Fitzgerald is very careful at assessment and introductory visits. He has had a number of referrals but refuses to take anyone that does not appear to fit the criteria of the home. He said that he feels that it is better to have vacancies than to have a resident in the home whose needs he cannot meet. Residents’ spoken to said that they had lots of visits before coming to the home and comment cards returned showed residents felt that they had received enough information about the home before they moved in to assist them in making up their mind about the home. One resident said “I couldn’t believe it when I got here. It’s better than anywhere else”. All residents have a contract/terms and conditions of employment, which are explained to them so they fully understand the agreement, and signed by them and the owner/manager. Copies of these, which are held in residents’ files, were seen on the visit. Duxbury House DS0000009789.V314827.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Assessments and care plans are detailed and informative, all changing needs are detailed as they occur, ensuring current needs are met. Residents are encouraged, guided and supported to make decisions and take informed risks and increase their independence and improve their decisionmaking skills. EVIDENCE: Residents’ records were seen. These described in detail residents’ emotional, health, care and support needs. Assessments and care plans are detailed and all changing needs are detailed as they occur. Residents are involved in developing plans and have agreed to these and signed their care plans. Care plans include ways of managing specific difficulties or behaviours and multi disciplinary meetings are put into place quickly and effectively where needed. If a resident moves into the home as an emergency admission, there are frequent multi disciplinary meetings, which eventually decide whether it is in the resident’s best interests to remain at Duxbury Lodge on a longer-term basis. Care plans are reviewed regularly and new goals agreed. Residents Duxbury House DS0000009789.V314827.R01.S.doc Version 5.2 Page 12 spoken to said that they had been involved in preparing and reviewing their care plans Discussion with the manager and staff showed that they had detailed knowledge about residents and their needs. Detailed risk assessments are in place, some relate to complex and difficult safeguarding adults issues. Residents are encouraged to take appropriate risks, to avoid high-risk behaviours and to look at the possible consequences of risks. Residents are encouraged and supported to make decisions, again looking at the possible options and how these affect themselves and others. Specific situations show the excellent care, support and guidance given to the resident. One resident said, “Vince (the owner/manager) talks to us but lets us make our own minds up about things”. There was good evidence that residents are consulted about anything that is planned in the home. Residents said that they chat to staff anytime and have regular residents meetings. Minutes of these meetings were seen. One resident said, “All the staff here are good, all very kind”. All residents are involved in routines and chores within the home. One resident is learning to cook his own snack type meals in preparation for eventual independent living. Others are involved in some meal preparation and assist with some daily living tasks. Duxbury House DS0000009789.V314827.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 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Contact with family and friends is encouraged and residents are supported to choose from a variety of leisure and educational activities, enabling them to be part of the local community. Residents are encouraged to recognise their rights and responsibilities and are supported to make the most of these to enhance their lifestyle. There is a good choice of meals with unhurried and relaxed mealtimes that meet resident’s needs. EVIDENCE: Some residents go to work training or college places. Others attend drop in centres as they wish. All residents have individual educational and leisure activities. One resident only ventures out for short walks or trips but enjoys staying indoors helping a little around the house. Another resident goes out and about alone and is unwilling to get involved in any work or college placement but is now happy to go out with the owner/manager on a one to one basis. Some residents need support to access leisure facilities others travel about unsupervised. All residents have the opportunity to have one to one leisure time with Mr Fitzgerald or other staff. One resident is learning how Duxbury House DS0000009789.V314827.R01.S.doc Version 5.2 Page 14 to drink alcohol socially without drinking too much. Another resident is developing leisure interests to expand his social life. Residents spoken to said that they could go out when they want. They also said how much they enjoyed the one to one leisure time. Residents said that they choose their activities with help from staff if needed. None of the current residents choose to attend a place of worship but would be supported to attend if they chose. Contact with family and friend is encouraged and staff help to arrange visiting if there is any difficulty. On the rare occasion a particular friend or contact is not welcomed into the home, Mr Fitzgerald explains the reasons to the resident and gets the residents agreement to this. It is then discussed at a multi disciplinary meeting and recorded. Mealtimes are flexible, unhurried and relaxed. There is a good choice of food. There is not a set menu but residents decide on meals with support and guidance. A detailed record of food is kept. Records showed that there is often more than one choice of meal each day. Residents said the meals were very good and tasty and they enjoyed them. Duxbury House DS0000009789.V314827.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Resident’s health and welfare is closely monitored to ensure health needs are met. Medication is stored, administered, recorded and disposed of correctly, providing a safe service. EVIDENCE: Records showed that efficient systems are in place to enable residents to receive appropriate healthcare support. Specific health issues are picked up on and acted upon quickly and sensitively. Residents use local community health services for physical and mental health wellbeing. Staff discussed specific issues and how they were approached gently and residents supported to take appropriate action. One resident was ill earlier in the year. Mr Fitzgerald and staff visited the hospital daily and monitored the resident’s health. Residents use local community health services for physical and mental health wellbeing. Staff support residents during medical appointments and health checks as each resident wishes. They are encouraged to take advantage of preventative health care but are supported if they choose not to accept this. Medication was checked and found to be satisfactory. No-one self medicates at present but previous residents have self-medicated in preparation for independent living. A Community pharmacist monitors the homes medication Duxbury House DS0000009789.V314827.R01.S.doc Version 5.2 Page 16 visiting every two months. They also arrange regular training updates with staff. Staff also recently visited the pharmacy and saw how medication is dispensed and had the opportunity to ask questions. This training will improve understanding of medication. Mr Fitzgerald regularly checks resident’ weights. He also checks his own weight along with residents so that the process appears less clinical and intrusive as they are all involved. Staff sensitively seek residents views on their support needs and choices in older age and death. Residents are well supported if friends or relatives are ill and through bereavement and loss. One resident’s relative is becoming increasingly frail, staff support the resident through this listening to concerns and ensuring visits are as frequent as they both want. Duxbury House DS0000009789.V314827.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The arrangements in place for handling complaints ensure that people feel confident that their complaints will be listened to and taken seriously. Procedures for dealing with and reporting safeguarding adults issues are in place to ensure that people are adequately protected. EVIDENCE: A detailed complaint procedure is given to all residents on admission to the home. There is also a complaints procedure in the hall of the home informing everyone how to complain. The home promotes an open safe culture where residents feel comfortable saying what they do and don’t want. All those spoken to or who returned the comment cards said that they were aware of how to complain if they wanted to and who to complain to. Residents said that they felt that staff listened to what they had to say. Staff are very aware of safeguarding adults issues and have been trained in protecting and supporting vulnerable people. There were in depth discussions of ways of keeping residents’ safe with the owner/manager and staff. Residents spoken felt safe and secure in the home and protected from harm. Duxbury House DS0000009789.V314827.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is good, providing residents with a comfortable and homely place to live. EVIDENCE: A tour of the home showed that the general environment was homely, clean, comfortable and well maintained. The owner lives on the premises and shares some of the facilities. There is a comfortable lounge/dining room, a kitchen that is well equipped, clean and tidy and there is a small separate laundry. All bedrooms are single. The bedrooms are not en-suite. Some residents showed the inspector their bedrooms. All rooms were individually and well personalised. Residents said they enjoyed their own space and privacy. One resident said, “I have my own room, it is nice” Resident surveys showed that they felt that the home was clean and fresh. New windows have been fitted to the home and new carpets have been fitted in most bedrooms. Piping has been replaced and some rewiring of the home has been carried out. There is an enclosed rear courtyard where tables and chairs are set out for residents to sit in the warm weather. Duxbury House DS0000009789.V314827.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this area is good. This judgement has been made using available evidence including a visit to the service. The relationships between staff and residents’ are good and create a caring ‘listening’ environment in which to live. Staff recruitment and training is good ensuring the safety of residents and good care practice in the home. EVIDENCE: Two new members of staff have been employed since the last inspection. These files were checked. They contained all the information required by regulation before new staff members commence working in the home. Recruitment is safe and ensures vulnerable people are protected. A detailed induction is provided ensuring staff have appropriate skills to care for residents. Staff in the home are well trained, skilled and according to the rotas seen were in sufficient numbers to meet the aims of the home and the changing needs of the residents. Residents said that there are always sufficient numbers of staff on duty. Information was seen to show that regular formal supervision is in place encouraging staff development and improving practice. Staff training is good. One of the two care staff was a nurse in another country and although not practicing as a nurse in this country has skills that are transferable to this employment. The other member of staff has completed National Vocational Qualifications (NVQ) level 2. The manager has completed Duxbury House DS0000009789.V314827.R01.S.doc Version 5.2 Page 20 NVQ 4 and plans to enrol on the Registered Managers award soon. All members of staff have attended other relevant training. Staff were observed interacting with residents in a caring and respectful manner. One resident said, “Staff are easy to chat to.” Another resident said, “Vincent and the staff here are the best you could have”. Duxbury House DS0000009789.V314827.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38 & 42 Quality in this area is good. This judgement has been made using available evidence including a visit to the service. The manager is providing clear direction in the home. It is effectively managed, supporting residents and staff. Good quality assurance systems are in place, enabling residents, relatives and staff have a voice. EVIDENCE: The owner/manager, Vincent Fitzgerald has many years experience as a manager caring for people with learning disabilities and mental health problems. Discussions with the Mr Fitzgerald indicated clear leadership, plans and a positive approach to the management of the home. He is enthusiastic and knowledgeable about supporting people with learning disabilities and mental health problems and this is passed onto the staff. He has completed NVQ 4 in care and hopes to enrol on the Registered Managers Award soon. He should do this to continue to develop good care and management practices in the home. The home is well managed and residents and staff feel well supported. One resident said “They will always help you here”. Another resident said, “Yes it is Duxbury House DS0000009789.V314827.R01.S.doc Version 5.2 Page 22 good here I can’t fault them. I can’t complain about anything here. They are very good.” Systems are in place for quality assurance. There are regular staff meetings and residents meetings and staff receive regular supervision. Views of residents and their relatives are also regularly sought informally. A colleague of Mr Fitzgerald ‘inspects’ the home every couple of months to check standards and ask service users and staff their views of the home. Staff training and good care practice were observed in the home and protect the health and welfare of residents, relatives and staff in most areas. Although the home has good fire safety checks, regular training for residents and staff, and all staff are knowledgeable about what to do in the event of a fire, there is no written fire risk assessment. One needs to be formulated for the home. The home has recently had an electrical check. Some remedial work was needed. It had been arranged for the contractor to complete this a few days after the visit. Some residents manage their own money, others need support to manage anything other than small amounts. Duxbury House DS0000009789.V314827.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 4 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 4 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 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 3 4 4 4 X LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 3 2 3 X X X 2 X Duxbury House DS0000009789.V314827.R01.S.doc Version 5.2 Page 24 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 YA42 Regulation 23 (4) (ac) Requirement The Registered Person must compile a fire risk assessment for the home. Timescale for action 02/12/06 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 YA42 YA37 Good Practice Recommendations The Registered Person should ensure the electrical work highlighted in the recent electrical inspection is carried out. The registered person should ensure the manager commences the Registered Managers award (RMA) Duxbury House DS0000009789.V314827.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Duxbury House DS0000009789.V314827.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. Re-publishing this information is in breach of the terms of use of that website. 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