Inspection on 29/08/06 for Gainsborough Avenue, 1a

This inspection was carried out on 29th August 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

Gainsborough Avenue, 1a 27/10/05

Gainsborough Avenue, 1a 12/05/05

Gainsborough Avenue, 1a 23/09/04

Gainsborough Avenue, 1a 27/04/03

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

CARE HOME ADULTS 18-65 Gainsborough Avenue, 1a 1a Gainsborough Avenue Maghull Liverpool Merseyside L31 7AT Lead Inspector Mrs Janet Marshall Unannounced Inspection 29th August & 12 September 2006 10:00 th Gainsborough Avenue, 1a DS0000005244.V300947.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 Gainsborough Avenue, 1a DS0000005244.V300947.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. Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gainsborough Avenue, 1a Address 1a Gainsborough Avenue Maghull Liverpool Merseyside L31 7AT 0151 520 3176 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) Expect Limited Mrs Shirley Tinsley Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 3 LD. The service should employ a suitably qualified and experienced manager who is registered with the CSCI 27th October 2005 Date of last inspection Brief Description of the Service: 1a Gainsborough Avenue is a small residential care home operated by Sefton Support Services. It is registered to accommodate three service users who have learning disabilities. Currently there are three women living at the home. The property is a detached dormer style bungalow situated in a popular residential area of Maghull. Its location is close to local amenities such as shops, public houses, and restaurants and is easily accessible to all forms of public transport. The home is well maintained both internally and externally and combines the requirements of a care facility with a comfortable domestic environment that gives no appearance of an institution. The philosophy of care continues to be focused on maximising independence for the service users and supporting them to achieve this. The current fees for the service start at £280 up to a maximum of £380 per week. Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection visit (site visit) at the home this inspection year. The inspection was unannounced and took place for a total of 6 hours. The Commission considers 22 standards for Care Homes for Adults (18-65) as Key Standards, which have to be inspected at least once in a 12-month period. All Key standards, which are identified within the main body of the report, were inspected during this inspection. During the site visit the requirements and recommendations from the last inspection report were discussed and checked with the registered manager. A number of them have been met. Those that have not been met have been raised again as part of this report as well as a number of requirements identified during this visit. A partial tour of the home was conducted. Care records and other required records were inspected. Records that were examined included a selection of resident’s care plans, daily diaries, medical notes, and medication and associated records, staff rotas and certificates of health and safety checks. Two residents were “case tracked”. Case tracking means that the Inspector concentrates on the care given and experiences of one or more residents to get an idea of what is like to live at the home and how that person’s needs are being met. A pre - inspection questionnaire, which was sent out to the home by the Commission was not returned as requested prior to the inspection. Discussions took place with residents, a number of relatives, the manager and staff. Their comments have been used as part of this report. What the service does well: The service is good at developing and keeping up to date care plans which reflect residents assessed and changing needs. The service is good at supporting residents to make choices and decisions and take risks as part of an independent lifestyle. The service ensures that residents enjoy a varied and fulfilling lifestyle by providing and supporting activities, hobbies and interests both at home and in the local community. The service provides residents with the appropriate personal and healthcare support, which ensures their well-being. The service has a good set of policies and procedures for responding to concerns and complaints and for ensuring that residents are safe from abuse, harm or neglect. The service is good at ensuring that the staff team have the qualities, qualifications and training that they need to meet the needs of the residents. Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 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 Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 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 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. Information is available and procedures are carried out to ensure that a person chooses the right home for them. EVIDENCE: There have been no new residents admitted to the home since the last inspection. Each persons care file contained information, which, showed that a full assessment of their needs was carried out by the home prior to them moving in. Needs assessments carried out by other people such, as social workers were also available. Policies and procedures relating to assessing and admitting new residents were available at the home. The assessment carried out by the home for the most recently admitted resident was viewed. It included a good level of information about the care and support needs of the person such as, health and personal care, mobility, communication and social support. Records showed that a care plan for the person was developed by the home based on their own and other assessments made. Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. Care plans provide the information that is needed to support residents to make choices and decisions and take risks as part of an independent lifestyle. EVIDENCE: A care plan for each person was available at the home. Two care plans were looked at in detail as part of the case tracking process. Both care plans covered all aspects of the persons personal and social support and healthcare needs such as personal care, medication, likes and dislikes, family and social contact, education/training and risk management. The resident, family members and the key worker had signed the documents to show that they were involved in and agree to the plan of care. Support guidelines were in place for residents who have difficulties with relationships, behaviour and community involvement. The guidance provided clear information for staff about how to manage such situations in a positive way and to the benefit of the resident. During the visit residents were observed making choices and decisions, which were appropriately supported by staff. One resident chose when to have a bath and what clothes to wear. The member of staff was seen providing the Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 Page 10 resident with assistance in a patient and polite way to which the resident responded positively. Because of limitations some residents are unable to make their own choices and decisions. This is because it is felt that it is not completely safe for the people to make the decision themselves or without the support of others. This information was recorded in the persons care plan and an up to date risk assessment had been carried out. Risk assessments provided staff with important information about how best to support people so that they can be independent in a safe way. Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. Residents enjoy a varied and fulfilling lifestyle. Opportunities for personal development could be improved upon to further promote independence. EVIDENCE: A personal development plan was part of each persons care plan. There aim is to encourage independence by identifying areas for development in the person’s life such as daily living, leisure and communication. The personal development plans that were seen identified goals and provided information about timescales and the people involved in supporting the person to achieve that goal. The section for recording comments showed little evidence of how or when the goal is monitored or the outcome. Identified goals included such things as days out to the theatre and trips to Blackpool. On examination of records and through discussion with residents it appeared that such events were a regular occurrence as part of the persons daily life and in accordance with their plan of care. Discussion took place with the manager about how the personal development plans could be better used to identify and monitor goals such as daily living skills. Examples that were Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 Page 12 suggested included making a bed and preparing a simple meal, tasks, which are realistic and achievable, and aim to develop the person’s independence. All residents are encouraged to be involved in daily routines of the house and activities of their choice. Records that were looked at and the following comments made by residents and relatives supported this: “I go to a day centre most days in the week, I really like going there” “There is plenty to do here, I go out a lot” “I have been apple picking” “I have been on holiday with staff and another resident who lives here” “I have my own computer, that’s it over there” (pointing to the computer in the sitting room). “I still enjoy pottering about in the garden” “I help around the house, I vacuum and tidy my own room” “I go to college a couple of days in the week, staff are very good they help me get there” “The staff take her out regularly” “She goes to the theatre and clubs of an evening” During the visit one resident was seen listening to music an activity, which she said, “I like a lot”. Case tracking showed that this and other activities described by residents were recorded in the relevant section of their plans of care. Discussion with residents and staff evidenced that relationships are encouraged and supported. The following comments made by residents supported this: “I visit my mum and dad and they visit me here at home” “My dad visits on a Sunday and I go out with him” “He is not my boyfriend anymore but he still visits me as a friend” On the day of the visit one resident attended a friends home for lunch. All residents have regular contact with friends and family records including the homes visitor’s book evidenced this. It was reported that there are no restrictions on visiting. The home provides a good amount of space so that residents can receive visitors in private if they wish. The dining room, which is located at the far end of the lounge, was bright and cheery. The kitchen was equipped with domestic style crockery, cutlery and appliances. Some appliances were damaged and could not be used by residents and the kitchen was generally in a poor state of repair. This is described in more detail in the environmental section of this report. During discussion a resident said “I always have enough to eat and can choose what I want to eat”, another resident said, “I have drinks and snacks when I want”. The home operates a 4-week menu, which was seen. Menus included a good selection of food that is healthy and varied in content. Food stores that were examined were well stocked with fresh frozen and dried goods. Two residents confirmed that staff help them to shop for food. Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 Page 13 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 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. Appropriate personal and healthcare support is given to residents ensuring their social emotional and physical well-being. EVIDENCE: Care plans included sections which recorded information about the persons health and personal care needs. Records, observation and discussion showed that staff are sensitive and flexible when assisting residents with personal care, their preferred routines were available in good detail. A member of staff was observed assisting a resident with various aspects of her personal care. The member of staff spoke to the resident politly and encouraged her to be self caring helping out only when necessary. The member of staff respected the persons right to privacy by ensuring doors were shut and knocking before entering rooms. Residents said that they choose when to get up and go to bed and what clothes to wear each day. On the day of the visit all residents were clean in appearance and attractively dressed. During discussion two staff members demonstrated a good awareness of the main principle of care, including privacy, dignity and respect. The following comments made by them supported this: Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 Page 14 “I always knock on residents bedroom doors before going in” “Residents should be respected, it is their right” “You should always speak to residents with respect, I would’nt like it if somebody spoke to me disrespectfully” Records showed that residents are offered minimum annual health checks and that their health care needs are well met, monitored and supported. All residents have been supported to attend GP appointments, dentists, chiropodists, hospital appointments and opticians. A residents relative said “the healthcare support seems to be good”. Details of appointments and outcomes were well recorded. Discussion with the manager and records showed that residents access health care services, which are located in the local community. Staff showed good knowledge and understanding of residents health and personal care needs. Daily records that were viewed showed that residents health care is monitored and that complications and problems have been identified and dealt with appropriately. A record of medication received and leaving the home was seen. Medication and medication administration records were examined. They were in good order. A policy for the safe handling and administration of medication was availble at the home. The manager said that medication is only administered by staff that have completed medication awareness training. A resident said “I always get my medication on time” Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 &23 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. Residents are protected by the homes procedures for responding to concerns and complaints and for ensuring that they are safe from abuse, harm or neglect. EVIDENCE: There has been no complaints received by the Commission about the home since the last inspection. There were no recorded complaints at the home. A number of relatives said they they had no complaints about the home, and that they had received no complaints from the residents. A complaints procedure was viewed at the home. It included good information about the stages and timescales involved in the process so that residents and other people are clear about how to make a complaint and the processes involved. The homes complaints procedure was not available in a format that can be easily accessed by the residents. The manager was advised to provide the procedure in a format that is accessible to all residents. Results of surveys and discussion with residents showed that they are confident about telling somebody if they were uphappy and that something would be done. The following comments supported this: “I do know who to talk to if I was unhappy” “I would not be afraid tell the staff about something that bothered me” “I know they would listen” A copy of the local Authorities Protection of vulnerable adults procedure was avaialbe at the home. Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 Page 16 Gainsborough Avenue, 1a DS0000005244.V300947.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The quality outcome in this area is adequate. This judgement has been made using available evidence including a site visit. Parts of the home are in an unsatisfactory state, which undermines the comfort, dignity and safety of residents. EVIDENCE: Most parts of the home were looked at on the day of the visit. Residents provided a tour of their bedrooms. One bedroom was nicely decorated and furnished to a good standard the room was personalised with items as chosen by the resident. The resident occupying the room said, “I like my room, I have a lot of my own things which makes me happy”. A requirement was given as part of the last inspection report to replace the broken handles to a resident’s bedroom furniture. Discussion with the resident and inspection of the room showed that this has not yet been done. Two doors on one resident’s bedroom furniture upstairs were broken off. A member of staff explained the reason for this and confirmed that arrangements had been made for the furniture to be repaired. One resident’s bed did not have a headboard, the member of staff could not give a reason for this and ensured that the resident would be offered one. Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 Page 18 As part of the last inspection report a number of recommendations were made to improve the environment. This was because there was evidence of wear and tear in these areas, which, undermined the comfort, and dignity of the residents. A tour of the home showed that the shared sitting room has been redecorated to a good standard. The room has also been fitted with new flooring. A resident said, “ I enjoy spending time in here both on my own and with company”. Additional handrails have also been fitted to the downstairs toilet/shower room making it more accessible for one resident. The resident said, “I can use the bathroom much easier now that the extra handrails have been fitted”. Other improvements recommended as part of the last report, which have not been made include repairs to the kitchen, main bathroom and the conservatory. Because of this they have deteriorated further and need attending to as described: Kitchen worktops were worn and damaged in parts and must be replaced. A number of unit doors, which were damaged and could not be shut must be repaired or replaced. The cooker and dishwasher, which were damaged and unsafe, must be repaired or replaced with new. The decoration, furniture and fittings in the upstairs bathroom, which were old and worn, must be replaced. The woodwork on the outside of the conservatory, which showed further signs of rot, must be repaired. All parts of the home and equipment used must be kept in a good state of repair to ensure the dignity, comfort and safety of residents. During this visit it was noted that all internal doors were badly marked and generally in poor condition. It was also noted that none of them were fitted with self–closures. Self-closures are fitted to the top of a door so that the door closes automatically after a person goes in or out of a room. They are required for fire safety reasons. Records at the home showed that the local fire authority had given following a visit to the home advice to fit all internal doors with self-closures. This must be addressed as described in the Conduct and Management of the Home section of this report. All areas of the home were clean and tidy at the time of the visit. A number of policies and procedures relating to the environment were available including, infection control cleaning routines. A resident said, “the house is always clean and tidy, I help to vacuum and clean my own room, which I like to do”. Gainsborough Avenue, 1a DS0000005244.V300947.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, 34 & 35 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. Staff appeared to have the qualities and receive training, which enables them to meet the needs of the residents, although there was no guarantee to this. EVIDENCE: At the time of the visit staffing levels were appropriate to the needs of the residents. Staff rotas were examined showed that there are sufficient staff on duty at all times throughout the day and the night. Staff personnel and training files could not be examined during this visit, this was because the manager had forgot to bring to work her keys to the cabinet were staff files are kept. Staff files must be made available for inspection by the manager to show that the homes recruitment, selection and training procedures are robust. During discussion a member of staff described the recruitment process that she went through. It included a completing an application form, an interview and police and reference checks. The member of staff confirmed that she took part in an induction programme during the first part of her employment. During discussion the manager and two members of staff confirmed that they complete regular training including health and safety, medication awareness, first aid, manual handling, food hygiene and Protection of vulnerable adults. Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 Page 20 A member of staff said, “The Company provide a good level of training, I have recently completed NVQ L3 in care first aid and manual handling training”. Another member of staff said, “The training is good, I enjoy it and am always happy to learn new things”. On the day of the visit one member of the staff team was looking forward to taking part in a team-building event, which was being attended by a number of other staff that work for the company including managers and directors. Through case tracking, observation and discussion staff showed that they have the qualities, are competent and have a good understanding of residents needs. Comments made about staff by residents and their relatives included: “They are all very good, very kind and caring”. “I like all the staff”. “Nothing is too much trouble to them” “The staff are excellent” Gainsborough Avenue, 1a DS0000005244.V300947.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, 39 & 42 The quality outcome in this area is adequate. This judgement has been made using available evidence including a site visit. In the main residents and staff benefit from a well-managed service, however this is undermined because of the risk to people’s health and safety. EVIDENCE: The manager has commenced the registered managers award. Since the last inspection the manager has been approved by the Commission as the registered manager of the home. This process has to take place to make sure that the manager has the qualities, competence and experience that she needs to do the job. Both residents and staff made positive comments about the manager which included, she’s great, very fair and approachable.” “Shirley is good, nothing is a problem for her”. “I like the manager, she is good at her job and I can talk to her about anything”. As part of the homes quality assurance process and in accordance with Regulation 26 of the Care Homes Regulations a representative for the home visits the premises monthly. They interview residents and staff, check records Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 Page 22 and inspect the environment. It is important that this is done to check the standard of care in the home. Following the visit a report detailing the visit is written and a copy is sent to the Commission. Records show that the visits and reports are being carried out each month as required. Residents and their representatives are also asked to complete a questionnaire, which gives them the opportunity to put forward their views and make comments about aspects of the home for example, the manager and staff, the quality and choice of food, and the environment. The results of the questionnaires are used to monitor the quality of the service. In principle the health safety and welfare of residents are well protected this was supported by a comprehensive set of policies and procedures, which were available at the home. A selection of health and safety records were examined including, fire system checks, gas and electricity checks and risk assessments for the environment. The records were up to date and accurate. During a tour of the home it was noted that none of the doors inside the house were fire doors nor were they fitted with self-door closures. This has the potential to put people at risk in the event of a fire. The manager must contact the local fire authority for advice regarding this and if required ensure that fire doors and/or self-door closures are fitted where appropriate. Gainsborough Avenue, 1a DS0000005244.V300947.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 X 2 3 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 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 2 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 X X X 2 3 Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 Page 24 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. No. 1. Standard YA24 Regulation 23(2)(b) Requirement All parts of the home and equipment used must be kept in a good state of repair. (This was a previous inspection requirement) The manager must contact the local fire authority for advice regarding fire doors. The manager must make staff files available for inspection. Timescale for action 31/01/07 2. 3. YA42 YA34 23(4)(a) 23(5) 17(3)(b) 31/10/06 30/09/06 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 YA11 Good Practice Recommendations Personal development plans should be improved to include more opportunities for personal development in practical life skills. Gainsborough Avenue, 1a DS0000005244.V300947.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Gainsborough Avenue, 1a DS0000005244.V300947.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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