Inspection on 27/06/06 for Edward House

This inspection was carried out on 27th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Edward House 11/07/07

Edward House 17/11/05

Edward House 14/07/05

Edward House 24/03/05

Edward House 18/01/05

Edward House 18/02/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Edward House Matson Lane Matson Gloucester Glos GL4 6ED Lead Inspector Simon Massey Key Unannounced Inspection 27 & 30th June 2006 10:00 th Edward House DS0000030393.V291585.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 Edward House DS0000030393.V291585.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. Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Edward House Address Matson Lane Matson Gloucester Glos GL4 6ED 01452 307069 01452 311742 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) Selwyn Care Limited To be appointed Care Home 9 Category(ies) of Learning disability (9), Physical disability (9) registration, with number of places Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Date of last inspection 17th November 2005 Brief Description of the Service: Edward House is part of the care provision offered by Selwyn Care Limited. The home is situated on the outskirts of Gloucester in the Matson area. The organisation provides residential and day care services to adults with Autistic Spectrum disorders and associated behaviours. The home shares the site with the organisational office, another home and the day care facility. There are spacious grounds around the home, with a lake, garden, fields and a large car park. All communal and individual accommodation is on ground floor level. There are nine single bedrooms all with full en-suite facilities. There are two spacious communal lounges, one incorporating a dining / activities area, as well as an additional dining room accessed via the kitchen. Just outside the main building there is a laundry area and an additional room, which is used for art and craft activities by the residents. The laundry and the art room have stepped access. The home has a Statement of Purpose and Service User Guide from which prospective service users can gain information about the service provided. The current fee range begins at £1725 per week. Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This unannounced inspection took place on the 26th and 30th June 2006. The inspector met and interviewed the manager, deputy manager and various members of the care staff team. Staff were observed supporting and working with the service users. Records relating to care planning, medication, staff recruitment, health and safety and staff training were examined. An inspection of the environment was also carried out. Following the previous inspection in November 2005 a number of requirements were issued to the home in respect of the service provided. Meetings have also subsequently been held between Selwyn Care and CSCI to discuss the action the Provider was taking. This inspection focused on the progress made towards the requirements made at the last inspection, and also looked at the majority of the core National Minimum Standards. What the service does well: What has improved since the last inspection? There has been a significant decrease in the number of challenging behaviours that have been displayed, which has resulted in an improvement in the general atmosphere within the home. Service users appeared relaxed in their environment on the days of this inspection. Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 6 A thorough auditing process for the administration of medication has been introduced. There is increased monitoring and supervision of staff. The care plans have continued to be developed and there are improvements to the risk assessments in place. The Company has appointed a new Head of Communication, a Training Coordinator and a Group Manager, whose role will include the supervision of the registered manager. This has resulted in a number of initiatives around training, and improved understanding around the area of communication techniques. 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. Edward House DS0000030393.V291585.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 Edward House DS0000030393.V291585.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): 2 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The admission procedure, if followed, ensures that people’s needs and aspirations are assessed prior to prospective residents moving into the home. This process should be followed for all admissions to the home. EVIDENCE: The home has admitted one new service user since the previous inspection. This person has arrived at the home from Italy, and the placement is being funded by the country of origin. There were no pre-admission assessments in place and an assessment of needs was completed after admission and in conjunction with the service users parents. The service user had been placed at some point previously at a school in this country, but at the time of the inspection no information had been sought from this source. This placement raises some concerns and the home are required to supply the Commission with the details of how this person’s needs are to be met. This relates to their physical and emotional needs in terms of professional healthcare input and also the care plan that has been developed since their arrival eight weeks previous. For example, the staff informed the inspector that they are required to communicate with the service user in English rather than Italian, on the instruction of the parents, but they are unsure what the service user’s level of understanding is. The service user has yet to communicate Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 9 verbally with any of the staff team, none of whom are fluent in Italian. The home are also required to supply information regarding the legal status of the service user in relation to their residency in this country and also any evidence that the service user has been supported to make an informed choice about their move to this country, and to Edward House. The home has an admissions policy that complies with the current regulations but it does not appear to have been followed in this case. Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Detailed care plans help ensure that needs are identified and guidance to staff provided. Improved staff training and input around communication should improve the opportunities to encourage choice and decision making for the service users. Risk assessing is used to promote independence and protect service users. EVIDENCE: The home has completed the revision of care plans that was required and all service users now have a plan in place in the new format. A sample of these were examined, and they were seen as detailed and covering a wide range of needs. The plans contain information about personal care required, special guidance for staff in relation to managing behaviours and additional information about interests and communication. There are risk management plans in place for Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 11 dealing with agitated behaviours and staff interviewed were able to demonstrate a good understanding of these. The plans examined had been reviewed monthly since January 2006. The files also contained the required bruise charts, weight charts and medication information. The files contained some examples of good recording though some notes were difficult to read. There is a sheet for staff to sign to say they have read the care plan, but on several this had only been signed by a handful of staff. There is a need for more detail to be recorded consistently in relation to descriptions of behavioural incidents. This particularly relates to antecedent behaviours, where some of the descriptors were quite brief. One service user has a recorded behavioural issue in relation to a member of staff who works in the organisation’s day centre. The care plan should record a protocol for managing this issue, evidence that professional advice has been given to the staff member concerned, and guidance to the staff in the home on how to provide consistent responses. A requirement has been made in relation to this. Examples were recorded in the notes of service users being encouraged and supported to make choices and decisions about their daily lives. This included choosing holiday destinations, trips out, food and the purchase of a mobile phone. The increased input that is planned around communication, detailed under the staffing standards, will also support staff to empower service users to make choices. A sample of risk assessments were examined and these were detailed and being reviewed on a regular basis. These provide guidance to staff around a variety of situations and activities. Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The majority of the service users enjoy structured and regular activities. Improved choice could provide greater variety and increased opportunities for people. A reasonably healthy and nutritious diet is provided but there is scope to improve choice and involvement in menu planning and shopping. EVIDENCE: Three service users spoken to stated that they enjoyed the activities they undertook, both during the week and at weekends. Examples were given of trips out, visits to parents and also interests that they pursued in the home, such as music, computers, collecting and writing letters. All service users have daily plans of activities, including attending the day— centre on site, art therapy and sensory sessions. There is scope to further develop the options and choices provided and it is intended that the increased Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 13 input around communication may facilitate service users making greater choices about the activities they choose to pursue. The care plans for some service users detail the support required to support certain activities. Records show that people regularly access facilities in the local community and surrounding area. Service users are supported to maintain family contacts with regular visits home, phone calls, letters and visitors being welcomed into the home. People stated they were satisfied with the quality and quantity of food and meals provided and were happy with the amount of cooking they were supported to do. People confirmed they had access to drinks and snacks when required and any limitations on access to the kitchen are recorded and risk assessed. The kitchen was stocked with sufficient fresh and packaged food at the time of the inspection. The menus are the same in both of the units and choice appeared to be limited at times, though staff stated that alternatives were offered when they knew that a service user disliked particular food. Choice around meals and menus is one area that the newly appointed head of communication will be looking at. Two staff commented that they thought there were possibilities for increased service user involvement in the planning of menus and the shopping for food. Staff were observed supporting service users in the kitchen dining area at lunchtime and the atmosphere appeared relaxed and unhurried. Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Health needs are closely monitored and appropriate professional input provided to meet the needs of the service users, and provide advice and guidance for the staff team. Clarification has been required over how the service user admitted from abroad will have their specialist healthcare needs met. Thorough and regular auditing of medication administration should ensure that professional standards are maintained and service users are protected from errors. Service users are also protected by a thorough process of training and accessing the competencies of staff who administer medication. EVIDENCE: The care plans detail the support that individuals require and also provide guidance to staff on how they would prefer this to be delivered. Individual files contain details of medical appointments and also information and correspondence from outside professionals. Staff record information following appointments in to the individual files. Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 15 Concerns about the provision of specialist healthcare for the latest admission to the home are outlined under Standard 2. Previous inspections have identified problems with maintaining a satisfactory standard of medication administration. The home has now introduced a thorough auditing and checking system that must be completed during every shift. This exercise is completed by two staff on duty and was observed being undertaken during the inspection. Action has also been taken to ensure that staff competencies are checked through training and supervision. All staff must complete the appropriate training before they are permitted to administer medication. Medication administration and storage was examined and found to be satisfactory. There are correct protocols in place to support one service user to selfmedicate and plans are being implemented to support another person to take more responsibility for their medication Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22&23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home responds to concerns and complaints that are raised but needs to ensure that all parents and relatives are aware the procedure to follow if they wish to make a complaint. The reduction in behavioural incidents has improved the atmosphere and service users appear relaxed in their home. Improved recording, and further staff training, will provide greater protection for the service users and help maintain the calmer environment within the home. EVIDENCE: The home has kept a record of complaints that have been made and subsequently investigated, and has also ensured that the Commission has been kept informed. Feedback has been provided to the Inspector that not all parents and relatives are fully aware of the complaints procedure that is available to them and a requirement has been made in this report that the home ensures that all families receive a copy of the policy and procedure for making complaints to the home. Since the previous inspection there has been a significant decrease in the number of aggressive or challenging behaviours that staff have had to manage. This is mainly due to the discharge of one service user, who often was in conflict with other residents of the home. There is a need to provide a protocol and guidance to staff on the managing of one person’s behaviour due to the possibility that staff may have to intervene Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 17 to prevent this person injuring themselves or a staff member. This issue was discussed with the manager. The recording of incidents was generally being completed in sufficient detail but there were some records where more detail of the antecedent behaviours could have been recorded. Various measures are being put in place, which should improve the home’s skill in managing of challenging behaviours. Staff are receiving training from Studio Three, which provides accredited training in managing challenging behaviours. The home intends to have their own accredited trainer in this area eventually. Improved protocols for managing behaviours are in place in all of the files and interviews with staff demonstrated an increased awareness of good practices that are required for working with people who have an autistic spectrum disorder. The Provider has appointed a full time training co-ordinator and a full-time Head of Communication. One of the intended benefits of these appointments is an increase in staff awareness and skills in working within a specialised service. Both were interviewed during the inspection and outlined a number of areas in which they intend to make improvements. Improved staff understanding of the autistic spectrum and improvements in the effectiveness of communication with service users should improve the quality of care provided. Examination of the rotas show that the agreed staffing levels are being maintained and where necessary this is being done with use of agency staff. Rotas and interviews with staff show that one to one staffing is being provided where this has been assessed as being required. The home will be providing staff training on Adult Protection. Service user finances were not examined during this inspection. Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service user live in a spacious setting, which meets their needs and is well maintained and decorated. EVIDENCE: An inspection of the environment was carried out and all parts of the home appeared well maintained and decorated and furnished to a good standard. The bedrooms are personalised and service users expressed satisfaction with their rooms and the privacy they provided. The laundry room was unlocked with the door open at the time of the inspection. Due to the materials stored there this should be kept locked when not in use. Staff explained that service users only access this area whilst under supervision and that the room is normally kept secure. One person has restricted access to the kitchen area and this is appropriately recorded. This situation was also observed being managed successfully by staff and service users. Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 19 The home was clean and hygienic throughout. Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Steps are being taken by the home to improve the quality and co-ordination of staff training, providing a more skilled workforce who are more able to meet the needs of people within the autistic spectrum disorder. Service users are protected by the home recruitment policy that complies with the current regulations EVIDENCE: Three service users spoken to expressed satisfaction with their key-workers and the support they receive. Service users were observed interacting with staff in a confident and relaxed manner. One person said that the staff were “nice”, and another that the “staff are good” and that their “key-worker was nice.” Whilst there is limited interaction between service users, people appeared reasonably comfortable within the group setting and, service users questioned, said they get on well with the other people in the home. Staff stated that usually challenging behaviours, when displayed, were directed at property or staff. This is supported by the evidence in the files, and the notifications received by the Commission. Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 21 Examination of the rotas show that the agreed staffing levels are being maintained, and where necessary this is being done with use of agency staff. Rotas and interviews with staff show that one to one staffing is being provided where this has been assessed as being required. Comments from staff suggested that further clarity could be provided around the provision of one to one staffing. An example was given of when service users decide to spend an extended period of time in their rooms and where the staff member should then locate themselves. A recommendation is made in relation to this. Supervision records showed that all staff were receiving regular recorded formal supervision. The team leaders have completed some in-house management/supervisory training. A sample of staff records were examined and these all contained the required details and information in relation to recruitment and pre-employment checks. A full time training co-ordinator has recently been appointed and they outlined their plans for the coming months. An audit of staff training has been completed and plans are place to ensure that all staff are up to date with the required statutory courses. A new Induction Programme has been devised for new staff, and a copy of this and the attendant workbook were shown to the inspector. Mentoring training will be provided for certain staff who will take on this role for newly appointed staff. Training will also be provided in Adult Protection, Moving and Handling, Autism and NVQ. The co-ordinator is an NVQ assessor and intends to support more staff to achieve these awards. The home provides training to staff from Studio Three in the managing of challenging behaviours. It is planned that this training will eventually be provided in house by the training co-ordinator. Training is also planned around Total Communication and Signing. As mentioned elsewhere in the report, more effective and consistent use of communication techniques should improve choice for service users and have a positive general impact upon the quality of care delivered. Several staff interviewed commented that there was an increase in the understanding and insight into the managing of autism amongst the team. The recently appointed Head of Communication has also identified a number of areas and issues they wish to focus on. It is evident that considerable resources are being put into increasing the skill levels of the staff team, both through ensuring the statutory training is up to date and providing the specialist knowledge that the client group demands. The only requirement made in relation to training in this report is that the home ensure that all staff are up to date with fire safety, food handling and first aid. Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 22 Staff interviewed were positive about the increased training provision and input around communication. Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 23 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Improvements in the administration and monitoring have led to more effective management in the home. The new management team are establishing goals and priorities which should provide direction and leadership for the staff team. EVIDENCE: A new manager had been appointed several weeks before this inspection and they were going through the registration process at the time of this inspection. There has been increased monitoring of staff, both formally and informally and action has been taken to address staffing conflicts and build confidence in the team processes. When appropriate, action has been taken by the management to ensure that the professional standards of practice required in the home are understood by the staff team. Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 24 There was evidence in the staff files, staff meeting minutes and supervision notes, that values and attitudes have been challenged by the management and attempts made to clarify to the staff team what is expected in terms of administration tasks, as well as work practices. The management team are taking action to provide direction to the staff team and attempting to ensure that the management is effective and consistent There is regular monitoring of health and safety, medication, staffing cover and maintenance issues. All fire safety checks have been completed and recorded and all equipment has been appropriately service and maintained according to the records. The home has a full time maintenance team who can respond to requests for repairs and improvements. Regulation 26 visits are being undertaken by the Director of Care, and staff confirmed that these have been unannounced. Reports have been forwarded to the Commission as required in the previous inspection. The newly appointed training co-ordinator has put forward a new Quality Assurance proposal that is being considered by the management of the service. The organisation has also recently appointed a new Group Manager who will supervise the managers of the registered homes. This is a significant change for the homes as it is intended they will receive closer supervision and support than has been provided in the past. This being due to the growth in the organisation. This appointment, and that of the Communication Co-ordinator and Head of Training, are positive and significant changes by the organisation that should support and further develop the improvement in the quality of care that is required. Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 1 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 2 x Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 26 No 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. 1. YA2 14 The home must supply the information to the Commission described in the text referring to the admission from abroad. 12(1)(a)&(b) The home must provide protocols/guidance for the managing of the service user’s behaviour as identified in the text of the report. 22(1) The home must ensure that all parents and relatives are aware of the homes complaints procedure 18©(i) The home must ensure that all staff are up to date with the required statutory training in first aid, fire safety and food handling 30/08/06 2. YA6 30/08/06 3 YA22 30/08/06 4. YA42 30/11/06 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 Refer to Standard YA32 Good Practice Recommendations Greater clarity could be provided to staff on the protocol for providing one to one support for service users. Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Edward House DS0000030393.V291585.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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