Inspection on 13/06/06 for Great Glens Facility Limited

This inspection was carried out on 13th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Great Glens Facility Limited 05/06/09

Great Glens Facility Limited 24/08/07

Great Glens Facility Limited 10/02/06

Great Glens Facility Limited 18/01/05

Great Glens Facility Limited 26/08/04

Great Glens Facility Limited 29/01/04

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

CARE HOME ADULTS 18-65 Great Glens Facility Limited 149/151 Midland Road Wellingborough Northants NN8 1NB Lead Inspector Irene Miller Unannounced Inspection 13th May 2006 10:00 DS0000012789.V294612.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 DS0000012789.V294612.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. DS0000012789.V294612.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Great Glens Facility Limited Address 149/151 Midland Road Wellingborough Northants NN8 1NB 01933 274570 01933 224729 darrylfoulds@greatglens.co.uk 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 Frank Leslie Foulds Mr Darryl Foulds Mr Darryl Foulds Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (22) of places DS0000012789.V294612.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To accommodate18 service users at 149/151 Midland Road, Wellingborough, NN8 1NB, PC by reason of mental disorder for the age of 25 years and over To accommodate 4 service users at 153a and 153b Midland Rd, Wellingborough in need of PC by reason of mental disorder, for the age of 25 years & over 10th February 2006 Date of last inspection Brief Description of the Service: Great Glen is a Home providing personal care for up to twenty-two young adult service users who have long-term mental health needs and have ongoing involvement with community based psychiatric support services. Accommodation is provided in the main building on two floors, in single bedrooms, each with an en-suite facility, and in a separate detached house next door, providing three single bedrooms for the more independent service users. Originally, Great Glen was registered as a ‘core & cluster’ establishment, with both houses managed by Mr Foulds. Facilities in both properties include recreation lounges, communal living rooms on both floors, with facilities for making hot drinks. There are limited adapted facilities to cater for physical disability, although currently the category of registration is only for service users with mental health needs with no physical disability needs. Externally, there are landscaped gardens with a large patio area. Great Glen is also well situated in a relatively quiet residential street not far from the centre of Wellingborough. DS0000012789.V294612.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for Service Users and their views of the service provided. This inspection was a ‘Key Inspection that focused on the key standards under the National Minimum Standards and the Care Standards Act 2000 for homes providing care for adults aged between 18-65. The primary method of inspection used on this unannounced inspection was ‘case tracking’ that involved selecting two service users and tracking the care they receive through review of their care plans, records, discussion with the service users, staff on duty, visitors and general observation of care practices and the environment. Mr Darryl Foulds the registered manager and joint provider was not available at the home on the day of inspection, however Mrs Jean Foulds the homes part owner, was the person in charge and was available at the home throughout the inspection. Prior to the inspection the Commission for Social Care Inspection sent out to the home a pre-inspection questionnaire, service users and visitors/relatives comment cards. Nineteen service users comments cards and ten visitors/relatives comment cards were returned to the Commission for Social Care Inspection. The preinspection questionnaire was not returned to the Commission for Social Care Inspection before the inspection took place, however it was available part completed within the home. Prior to the inspection taking place, the inspector spent three hours planning the areas to focus on at this inspection, based upon information gained from reviewing the homes service history, the last two inspection reports, the comment cards received from service users and relatives/visitors. The inspection took place over a period of six and a half hours. What the service does well: Information about the home is made available to all residents, copies of the homes Statement of Purpose (that outlines the qualifications and experience of the registered provider and manager, and the range of care that the home is registered to provide) are available and all residents are provided with a copy of the Service User Guide (that outlines the range of services available within the home, and daily routines) DS0000012789.V294612.R01.S.doc Version 5.1 Page 6 Prospective residents are invited to visit and to stay overnight at the home on a number of occasions prior to moving into the home, to ensure that every opportunity is given for them to be sure that they are happy with moving in. Residents are supported in maintaining their skills and independence, by participating in the day-to-day, domestic life within the home. Residents said that staff are very respectful and supportive and know that staff would be there for them whenever they need someone to talk to. There is a loyal, trained and experienced staff group with a low staff turnover, which ensures consistency of care for the residents living at the home. The leadership of the home promotes a consistency of high quality care, which safeguards the resident’s health, safety and welfare. 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. DS0000012789.V294612.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 DS0000012789.V294612.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 excellent. This Judgement has been made using available evidence including a visit to the service. Residents who enter the home can be confident that their needs and expectations can be met. EVIDENCE: The home has a statement of purpose and a service users guide that outlines what the service can and cannot provide. Contracts of care are in place, which outline the homes terms and conditions for service users, and signed by service users. Full assessments of prospective service users needs are conducted prior to admission, the pre assessment documentation identifies aims and objectives on how the home will meet service users needs and expectations. Prospective residents are invited to visit the home on a number of occasions prior to moving in, there was one vacancy at the home and a room was being decorated ready for the new resident, the person in charge said that the prospective resident had been to the home on a number of occasions and was looking forward to moving in. DS0000012789.V294612.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to the service. Residents are supported to remain in as much control over their lives as possible EVIDENCE: Residents said that they were aware of their care plans and had involvement with them, with the support of their keyworkers, the care plans were clear and specific, outlining personal aims and objectives to promote independence. The residents said that they enjoyed attending the educational sessions provide by Thresham College, such literacy, numeracy, IT and arts and crafts. The courses provided by Thresham college had been suspended until September 2006, residents said that they would miss participating in the sessions and were looking forward to them resuming again. DS0000012789.V294612.R01.S.doc Version 5.1 Page 10 Residents said that they felt useful participating in the day-to-day domestic life within the home, doing their own laundry, washing up, shopping and housework, and were proud of their achievements in developing more independence in their lives. Service users were observed within the home assisting with light domestic tasks, working in the homes kitchen with staff assisting with the preparation of the mid-day meal. There were general risk assessments in place covering internal environmental hazards, such as the control of substances hazardous to health, cross infection control, working within the Kitchen environment and smoking hazards. Where there was an identified area of risk to individuals due to their work activity and lifestyle choices, risk assessments were available within their individual care plans Within the care plans seen, there were risk management plans in place, however there was no documentation available to demonstrate that these had been regularly reviewed. Care programme approach (CPA) reviews had taken place with healthcare professionals and there was documentation available within the care plans to demonstrate that the programmes had been reviewed. One resident who had recently moved out of the main house into one of the supported living houses on site, said that they really enjoying the newfound feeling of independence and were proud of their achievement in gaining a more independent lifestyle. Saying that they were aware that a risk assessment would need to take place in relation to them using the oven and hob within the house to cook and prepare meals independently and that until the assessment takes place they help prepare meals over at the main house with support from the staff. DS0000012789.V294612.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents are enabled to maintain appropriate and fulfilling lifestyles in and outside of the home. EVIDENCE: The resident’s contracts set out the terms and conditions of residency and contracts seen had been signed by the resident. Residents spoken with said that they were happy living at the home, observations of staff and resident interactions was very positive with residents being encouraged to exercise their individuality, and pursue their own interests. DS0000012789.V294612.R01.S.doc Version 5.1 Page 12 Residents are encouraged to have regular contact with family members and maintain friendships. Residents said that relatives visit them and at other times they may visit their relatives. Residents spoken with said that staff ‘really make an effort’ and that they are very respectful and supportive, the residents said that they know that staff would be there for them whenever they need someone to talk to. Staff spoken with confirmed that there is a system in place to provide each resident with additional 1-1 support Residents spoken with that lived within the on site independent living accommodation, said that they enjoyed having their independence and were confident that help would be available if they need it. Residents were observed going about their daily tasks, shopping and doing the housework. Residents spoke of day trips taking place to Great Yarmouth and Skegness and individual outings shopping, going to the pub and fishing. Plans were underway to take two residents and their support workers on a long weekend to Brussels in July, one of the residents that was due to go on the trip was available to speak to and said that they were really looking forward to the weekend and had been saving up for it. Some of the residents attend a local gym, attending on average two to three sessions per week, and were very aware of the importance of eating a balanced healthy diet, saying that they enjoy going out shopping and preparing healthy foods. The larder within the main house and the food cupboards within the independent houses were well stocked and contained a range of healthy eating options. Residents participate in devising the menus and in the preparation and serving of meals. In general the residents are happy with the meals provided. One resident said that they have the opportunity to cook Caribbean foods, which they had not quite perfected yet. DS0000012789.V294612.R01.S.doc Version 5.1 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 Quality in this outcome area is adequate. This Judgement has been made using available evidence including a visit to the service. The resident’s personal, emotional and health needs are met with respect and sensitivity, however the lack of formal reviews to residents risk management plans could place them at risk of their needs not being fully met. EVIDENCE: The staff were observed offering support to residents in a relaxed way, the care plans provided the information for staff to follow in meeting their needs. Residents are supported and encouraged to go out into the community independently and with supervision. The residents care plans contain detailed risk management plans with the action for staff to follow in ensuring that the health; safety and welfare of service users are met. However no documentation was available to demonstrate that the risk management plans had been reviewed DS0000012789.V294612.R01.S.doc Version 5.1 Page 14 The residents care plans seen demonstrated that support is provided for the service users to manage their own health care and attend local clinics for specialist health care needs. Residents who self-administer their medication were observed liaising with staff and signing for medication that they had taken. The storage and administration of the homes medication was viewed, for one resident a record of refusal to take the prescribed medication, had been entered on the medication administration record (mar) sheet, however on speaking with staff it was explained that the resident had not refuse their medication and that, the reason the medication had not been administered was due to non compliance from the resident to attend for their medication within a set time period. It was explained that if this behavioural approach is to be used that it should be only adopted following full consultation and agreement between the resident, their general practitioner and other relevant healthcare professionals involved in the resident’s care. There was not record with the residents mar sheet nor within the residents individual care plan in relation to any decision of medication being withheld when the resident has not attended for their medication. DS0000012789.V294612.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to the service. The home has a complaints and adult protection system in place, that could benefit from being further developed. EVIDENCE: Residents spoken with said that they would know who to speak with should they have any concerns about the service. Staff were knowledgeable and confident about their roles and responsibilities in relation to the Protection Of Vulnerable Adults. There is a policy on the Protection Of Vulnerable Adults, which includes reference to the Northamptonshire multi agency policies and procedures for the protection of vulnerable adults. However the homes policy on the protection of vulnerable adults would benefit from being reviewed and updated with current contact details to ensure that any suspected or actual allegation of abuse is dealt with following the multi agency approach. There is a Complaints Policy available, however feedback from the residents and visitors comment sheets indicated that the policy would benefit from being more readily available to residents and visitors, should they need to refer to it. DS0000012789.V294612.R01.S.doc Version 5.1 Page 16 No complaints had been received at the home prior to the inspection taking place and the Commission for Social Care Inspection has not received any complaints about the home. DS0000012789.V294612.R01.S.doc Version 5.1 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 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to the service. The home is clean, safe, comfortable and homely and is appropriate for the resident’s lifestyles and needs. EVIDENCE: A limited tour of the premises took place the home was safe, comfortable with furnishings and fittings domestic in nature. There are small communal areas where residents could choose to be alone if they wished to do so. Residents that smoke use the main lounge and there is a small no smoking lounge available for non-smokers if they wished to use it. Residents are discouraged from smoking within their own bedrooms due to the safety hazards surrounding this practice. DS0000012789.V294612.R01.S.doc Version 5.1 Page 18 The residents bedrooms viewed were personalised and homely, a window restrictor had been fitted to the window of one resident’s rooms on the first floor, following the last inspection that took place in February 2006.were it was identified as missing. Within this room there was evidence that the resident had been smoking within their bedroom, cigarette ends were placed in a wicker basket within the bedroom, the potential fire risk was discussed with the person in charge and measures needed to reduce the fire risks to an acceptable level were discussed. The door leading to the kitchen had a self closure in place, however due to the consistent use of the kitchen area, the automatic closing of the door presents an obstacle and a presented a potential hazard to staff and residents, when carrying hot foods and drinks, hence a door wedge was in use. The possibility of fitting a sound activated hold open device to this door, to ensure that the door closes automatically in response to the fire alarm being activated was discussed with the person in charge. The opinion of the fire authority prior to the purchase and the fitting of such a device would be beneficial. Residents who are capable of taking responsibility of their own laundry are supported to do so, and within the independent living house there was evidence of the residents involvement in doing their laundry. The toilet and bathroom were clean and free from offensive odours and the broken tile identified in the last inspection had been repaired. Cleaning materials were stored within locked cupboards and (Coshh) Control of substances hazardous to health data sheets were available for all the cleaning chemicals in use Under the support and supervision of staff, residents take an active part in day to day food preparation and cooking activities, therefore access to the domestic cleaning materials within the kitchen environment is required to ensure that the food preparation and cooking environment is maintained to a high standard. Within the kitchen environment there was a small supply of domestic cleaning materials stored within a cupboard under the sink unit, items such as washing up liquid, surface sanitizing spray and scouring pads were available for use. The home has carried out a risk assessment of residents using the cleaning materials, within the kitchen environment and the likelihood of a resident being at risk of coming into contact with the domestic cleaning materials has been assessed as low risk. Risk assessments have been conducted on the accessibility of sharp kitchen knifes and to reduce the risks these are stored within a locked drawer and counted on a daily basis. DS0000012789.V294612.R01.S.doc Version 5.1 Page 19 The kitchen was clean and tidy, records were maintained of cleaning schedules and temperatures of cooked foods and daily fridge and freezer temperatures were retained and were up to date. Records were maintained of weekly fire test, and emergency lighting tests, and records were available of maintenance to the fire equipment, gas and electrical systems. DS0000012789.V294612.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. The staff team are skilled in caring for the residents living at the home. EVIDENCE: All staff spoken with demonstrated good relationships and had in depth knowledge of the needs of the Service Users, and they were knowledgeable about the aims and objectives of the home. The staff training documentation looked at contained evidence of induction and foundation training taking place. The home has a loyal, trained and experienced staff group with a low staff turnover. Staff are encouraged to develop their skills in caring for the residents further and are supporting through their National Vocational Qualification 3 (NVQ3). Staff spoken with confirmed that they had attended various training courses relevant to their role within the home. Staff spoken with confirmed that there is a system in place to provide each service user with additional 1-1 support sessions and that each week there is DS0000012789.V294612.R01.S.doc Version 5.1 Page 21 an extended handover that takes place to ensure that communication regarding the care of the residents and their changing needs is conveyed. Staff spoken with said that they are kept informed of developments and new initiatives within the home, through monthly team meetings. Three staff recruitment files viewed, contained information to demonstrate that the home ensures that good recruitment practices are carried out. A new member of staff had recently taken up post, whilst the home was awaiting the criminal record bureau clearance; the member of staff was undertaking their induction programme and was under the supervision of an experienced member of staff. Staff spoken with confirmed that they feel well supported by the homes management, and that there are opportunities to access training relevant to their role and their academic levels. DS0000012789.V294612.R01.S.doc Version 5.1 Page 22 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 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to the service. The leadership of the home promotes a consistency of high quality care, which safeguards the residents health, safety and welfare. EVIDENCE: It was observed that residents were at ease with the staff Team, residents were observed to come and go as they pleased and to treat the home as they would their own home. When residents were asked what the home does well they said that the staff are very respectful and “they really make an effort” saying that they are allowed to be as independent as possible. The registered manager was not available on the day of inspection and there was no detrimental effect to the smooth running of the home due to his DS0000012789.V294612.R01.S.doc Version 5.1 Page 23 absence. Staff were observed skilfully alleviating residents anxieties offering reassurance and support, conducting themselves in a professional manner. The home has a range of policies and procedures in place that staff have access to at any time. The home has a policy on the protection of vulnerable adults and also has the Northamptonshire multi agency policies and procedures available for reference. The homes own protection of vulnerable adults policy would benefit from a review to ensure that it contains the current contact details and reporting protocols, however on speaking with staff it was demonstrated that staff are aware of the procedures to follow, should a protection of vulnerable adults issue occur. The home has a complaints policy in place and copies of the policy are available to residents within their bedrooms on the back of the door. The complaints procedure is available within the homes statement of purpose, however feedback from the residents and visitors comment sheets received by the Commission for Social Care Inspection prior to the inspection, indicated that some visitors are not aware of the complaints policy and that the policy would benefit from being more readily available to visitors, should they need to refer to it. Records were available of maintenance checks to the electrical, lighting, gas, water and fire systems and equipment. The home had recently had an inspection from the fire authority and was awaiting the report following the visit. Records were available of scheduled checks undertaken by the home of the fire system and emergency lighting system. A system was in place to record identified faults that staff come across during the course of their work, and there was some faults that had been reported that were awaiting action such as a faulty electrical socket and a toilet light that was not working that required the attention of a qualified electrician, the person in charge made arrangements for the work to be done whist the inspection took place. The home is committed to promoting the health safety and welfare of residents and staff and systems are in place to ensure that they live and work within a home that is safe, clean and homely. Great Glen holds the ‘Investors in People’ award, and is committed to continuous review of the services provided. DS0000012789.V294612.R01.S.doc Version 5.1 Page 24 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 X 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 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 3 3 X 3 3 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 2 X 3 X 3 X X 3 X DS0000012789.V294612.R01.S.doc Version 5.1 Page 25 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. Standard Regulation Requirement Timescale for action 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 YA6 Good Practice Recommendations The risk management plans within the care plans should be reviewed at least six monthly, and updated to record changing needs, any agreed changes should be recorded and actioned. Full consultation and agreement between the resident, their general practitioner and other relevant healthcare professionals should be sought and documented, before any staff decision is made to withhold resident’s medication. The policy on the protection of vulnerable adults should be reviewed to include the adult care squad contact details. The advice of the fire authority should be sought prior to the purchase and fitting of a fire sound activated devise to the kitchen door. 2 YA20 3 4 YA39 YA42 DS0000012789.V294612.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 DS0000012789.V294612.R01.S.doc Version 5.1 Page 27 - 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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