Inspection on 06/03/07 for Herbert House

This inspection was carried out on 6th March 2007.

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

Herbert House 20/02/09

Herbert House 30/01/06

Herbert House 24/08/05

Herbert House 26/11/04

Herbert House 27/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Herbert House Christie Miller Road Salisbury Wiltshire SP2 7EN Lead Inspector Pauline Lintern Unannounced Inspection 6th March 2007 09:45 Herbert House DS0000028638.V330989.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 Herbert House DS0000028638.V330989.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. Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Herbert House Address Christie Miller Road Salisbury Wiltshire SP2 7EN 01722 413244 01722 416096 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) www.rethink.org Rethink Mrs Marion Yeates Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (15) of places Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2006 Brief Description of the Service: Herbert House is a care home offering accommodation and support for up to fifteen people who have a mental health needs. The home is run by Rethink and is located in Salisbury. Public transport, shops and other amenities are nearby. It is an attractive home, with accommodation over two floors, including a lounge, a large kitchen and dining room, and a conservatory. It is light and airy, with comfortable furnishings, and all residents have single bedrooms with en-suite showers. There is a separate flat available for two people who wish to retain more independence. There are large mature gardens at the rear of the house, and parking at the front. Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection took place over 6 hours. The manager Marion Yeates was present throughout the inspection to assist the inspector. At the time of the inspection ten residents were at home and the inspector was able to meet eight of them. Three residents spoke to the inspector in private. Ten survey forms were sent out prior to the inspection to relatives, residents and healthcare professionals. We received four responses from residents, two from relatives and one from a purchaser. The inspector toured the premises, met with staff members and examined various records. These included care plans, risk assessments, medication records, complaints records, staff recruitment records and training records. The fees currently charged at Herbert House are £639 per week. What the service does well: A full assessment of the resident’s needs is completed to ensure that the home can meet them. Residents have the opportunity to visit the home and are provided with information to enable them to decide if they wish to stay there. Information is provided in leaflets, the statement of purpose and a service user guide. Each resident has an individual care plan, which has been agreed with him or her. The care plans are in a clear, easy to read format and are underpinned by risk assessments. Both care plans and risk assessments are regularly updated. The home appears to be constantly looking at ways of further developing the service, which they provide. For example the inspector was shown the recently introduced ‘recovery plan’, which enables residents to evaluate their skills and monitor their successes. Since the last inspection there has been a great improvement to the décor of the house and many new pieces of furniture has been purchased. At the last inspection three requirements were made and these have now all been addressed. Comments gathered from residents, relatives and healthcare professionals were all generally positive. Comments include: They are excellent at communicating with me whether it’s concerning small or large concerns. They are very supportive to both resident and their family. Herbert House has done a lot for my son and achieved things for him that I was unable to do. [My care worker] is easy to talk to if you have a concern. Staff are nice to me. It’s like a boot camp; I have to get up for breakfast meetings. I am impressed with the way in which Herbert House manage the care of residents, the focus on rehabilitation, and the way in which residents are supported in engaging in outside activities. Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 Page 6 The staff impress me with the way in which their approach is thorough and professional, with appropriate boundary setting regarding residents’ behaviour, but also friendly and caring. 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. The summary of this inspection report can be made available in other formats on request. Herbert House DS0000028638.V330989.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 Herbert House DS0000028638.V330989.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good Prospective residents have a full assessment of their needs, prior to being offered a place at the home. To enable potential residents to make a decision about where they live, information is provided within the statement of purpose and the service user guide. Rethink information leaflets are also available. This judgement has been made using available evidence including a visit to this service. Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 Page 9 EVIDENCE: Resident’s confirmed that they were provided with information about Herbert House prior to moving in. There is an opportunity for potential new residents to visit the service and sometimes to stay overnight. Each service user is provided with a service user guide, which details the purpose and philosophy of the home along with information on activities, leisure and employment opportunities, involvement in the running of the home, catering, confidentiality, visitors, fire precautions, catering, medication, fees, personal money, how to make a complaint and information about the manager and the staff team and their relevant qualifications. There is information on the referral and admission process and how each person’s recovery plan will be actioned. Residents are made aware of any restrictions set by the home and terms and conditions of the home are clearly outlined. There is also a statement of purpose, which the manager reports is currently in the process of being updated. Records show that each resident has had a full assessment of their care and health needs completed to ensure that the home is able to provide the support needed by the person. The assessment covers accommodation, education, training, occupation, social and family needs, risk, physical and mental health needs, finance and specific condition related needs. Residents sign a form to consent to the sharing of their information. Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is excellent Each resident has an individual care plan, which reflects his or her assessed needs. Care plans are regularly reviewed. Residents are able to make decisions about how they choose to live their lives, with staff support if necessary. Risk assessments are completed and reviewed to enable residents to lead an independent lifestyle. This judgement has been made using available evidence including a visit to this service. Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 Page 11 EVIDENCE: Two case files were sampled as part of the inspection process. Each care plan reflects the person’s assessed needs and has been signed by the resident. They record how personal and social support is to be provided and how a person’s healthcare needs will be met. Each resident has a designated key worker to ensure consistency. One resident commented that they “ get on really well with their key worker” and that he “ encourages me to keep my bedroom clean”. Residents attend their review meetings and have the opportunity to record their comments on the reviewed plan. One resident had written, “ I am pleased with myself and with what I have achieved”. Residents have the opportunity to fully participate in the planning of their care. The team leader explained that they have recently introduced casework meetings, which involves the resident and the key worker. This has proven to be a success so far. The inspector was shown a newly developed format for a recovery plan. The plans are clear and concise in their content and will provide a record of identified needs, action required, residents’ view of the progress and also the key workers views. Identified goals are then broken down into achievable weekly goals, which can be easily evaluated by the resident and his or her key worker. The manager explained how one resident had set their heart on learning to drive and after many attempts has now passed their test and is now the proud owner of their own car. The manager reported that their determination to reach their goal has been an inspiration to other residents. Residents confirmed that they are encouraged and able to make decisions on how they choose to live their lives. One resident reported that they choose not to attend college or social events /activities as they “ have enough mates and do not wish to make any new ones”. On the day of the inspection staff members were observed encouraging residents to make their own decisions. The manager and team leader explained that they are ‘fairly strict’ on encouraging residents to participate in house meetings and group discussions to ensure a consistently good attendance. The manager reported that although there is information provided on how to access an advocate if required at the present time no one has advocacy support. Where there are any restrictions in place this is clearly recorded in the individuals care plan. Any potential risks are clearly identified and measures put in place to minimise them if possible. Assessments are regularly updated and discussion with the manager confirmed that this done with the residents consent if appropriate. Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good Residents have the opportunity to take part in appropriate activities within the local and wider community. Leisure activities are available if residents choose to attend. Residents can choose to meet friends and family if they wish. Staff members respect residents’ rights and recognise their responsibilities in their daily lives. Meals are varied and chosen by the residents. Staff members promote a healthy diet for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 Page 13 There is evidence to show that staff members support residents to take up opportunities for further education and literacy and numeracy training. One resident explained that they are attending a college course in numeracy level two; they have already passed level one. They added that they were looking at the options open to them for future employment. Another resident reported that they are currently attending a painting and decorating course and a staff member was observed explaining to the resident how there is a need for more painters and decorators in a supportive and encouraging manner. The team leader explained that two residents attend ‘Parkway Plants’ where they help out with various tasks. At the present time seven residents regularly attend college. The home has a strong commitment to enabling residents to achieve their goals, and working to achieve them. As mentioned previously in this report the resident who passed his driving test is a good example of how staff have offered support and with the residents motivation and determination, goals have been reached. During the inspection the resident was seen offering to provide a ‘lift’ to other residents in his car, enabling easy access to the local community for them. There is evidence from speaking to residents that the staff team reflect the diversity and cultural needs of residents by not trying to impose their own values on individuals. One member of staff commented, “I feel that we respect residents’ rights here”. One resident explained to the staff members and the inspector how they had enjoyed the weekend away at a kickboxing event and explained that they hoped to attend another similar event later on in the year. Another resident informed the inspector that staff members had helped them to identify a ‘body combat/street dance’ class and they are hoping that they will be able to attend. The home has a notice board, which informs residents of local events, activities and opportunities available to them in the local community. One staff member suggested that it would be good if the residents could have access to the internet. Residents have unrestricted access and can come and go as they please. Staff members do not enter resident’s bedrooms unless they are invited to do so. All residents have a key to both the front door and their bedroom, although the manager reported that some residents choose not to lock the door to their bedroom. Discussion with the manager regarding residents’ rights indicates that there is a good understanding of residents’ rights and also the staff’s duty of care. The service user guide and the statement of purpose outline the expectation that the resident will maintain their room to Herbert Houses’ standards. Residents are able to meet friends and family in private if they choose. Some residents go home at weekends to stay with their family. Residents were observed interacting with staff members. Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 Page 14 The door to the main office is generally kept open when staff are in there and residents appeared to feel comfortable and at ease just coming in for a chat with staff whenever they wish. The atmosphere was relaxed and friendly. The home is an alcohol free house, however residents are able to go out for a social drink if they choose. The menu was observed over a three-week period. Meals appear nutritional and varied to take into account everyone’s preferences. Each resident chooses their own menu and some residents are self-catering, which means that they also purchase their own food. There is a large fridge for individuals to store chilled goods, which they have purchased. Residents confirmed that the food is good and that they can help themselves to a snack when they wish. Any specific dietary needs relating to low fat diet or weight-gaining diet is documented in the individual’s care plan. One residents survey form returned to us commented that they would like to be able to take responsibility for deciding if food was ‘out of date/best before’ and not rely on the staff team to make this decision for them. This was discussed with the manager who agreed to explore this further to see if they could reach an agreement with the resident that was reasonable without placing them at risk Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good At the time of the inspection none of the residents required support with their personal care. The home ensures that the healthcare needs of residents are being met. Medication is managed well to protect residents where possible however staff members need to be reminded of the procedure for recording the refusal of medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 Page 16 Standard 18 was not fully inspected as none of the residents required support with their personal care. The manager explained that some residents did need encouragement with maintaining their personal hygiene. One resident reported that they love jewellery and developing their own style of dressing. They added that they enjoy mix and matching new clothes with clothes they have discovered at charity shops. Residents confirmed that times of going to bed and getting up are generally flexible although they are encouraged to get up and take part in the breakfast meeting. All residents have access to healthcare professionals. Records show that appointments are made and kept with doctors, opticians, psychiatrists and community psychiatric nurses when required. All residents attend mental health reviews on a regular basis and this is then reflected in the care plan. There are good mechanisms in place for managing medication. The manager explained that Rethink is presently updating their medication policy and any amendments will be made ‘in house’ accordingly. Currently only a couple of residents self medicate and staff members monitor this. At the present time residents do not pick up their own prescriptions, however the team leader reported that this is something, which they are looking into for the future. Medication records were examined and generally were in good order. There was a few gaps on one resident’s record, however staff members confirmed that this had been an oversight by staff when a resident had refused their medication. The manager confirmed that she would remind staff members of the importance of keeping correct records. There is an ‘in house’ induction specifically on medication issues. Both the staff member and the manager sign to confirm that they are competent in this area. No staff member administers medication unless they are trained to do so. The manager confirmed that they have recently received medication training from Boots, which included any new staff and existing staff members. Discussion took place regarding the recording of certain medication and the inspector agreed to forward further guidance to the home, which has now been actioned to ensure good practice takes place. Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good Residents confirmed that they feel they are listened to and their views are acted upon. Where possible residents are protected from any form of abuse, neglect or self-harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes’ statement of purpose and service user guide details the procedure for making a complaint or raising a concern. It states that the complaint will be acknowledged within three working days. In all cases complaints will be followed up with a written response within twenty working days. The manager reports that there have been four complaints during the last twelve months; three were substantiated and one partially substantiated. All were responded to within twenty-eight days. Three residents confirmed that they have not needed to make a complaint but each person knew how to do so if necessary. There is a complaints log kept at the home, which records the outcome of any complaint made. Four of the residents who returned survey forms to us confirmed that they knew who to speak to if they were unhappy; one person said that they did not know who to contact. The home has copies of the local ‘No Secrets’ protocols for responding to allegations of abuse. There have been no adult protection investigations in the last twelve months. Staff attend training on safeguarding vulnerable people and the home has a ‘whistle blowing’ policy. One member of staff confirmed that they “would be happy to raise any concerns” that they may have. Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good Herbert House provides residents with a homely, comfortable and safe environment. The home was found to be clean and hygienic. This judgement has been made using available evidence including a visit to this service. Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 Page 19 EVIDENCE: There have been many improvements made to the home since the last inspection. New furniture, carpet, curtains, lamps, pictures and plants have been purchased. Rooms have been decorated including the room, which had previously been the smoking room. This is now another light, airy and pleasant room for residents to relax in if they wish. The manager explained that as recommended at the last inspection they have given consideration to extending the fence around the property. However this was discussed with the residents and the generally consensus was that they would prefer to grow some large shrubs and trees in this area instead. A member of staff was going to the garden centre on the day of the inspection to purchase them. The manager confirmed that the following day they were having security lights fitted around the premises to increase security. It was noted at the last inspection that one bath had flaking enamel and it was recommended that this be replaced. The manager reported that she has received confirmation that this will be replaced during 2007/08. At the time of the inspection the home was found to be clean and hygienic throughout. There is a separate laundry, which houses the washing machine and tumble drier. Staff members receive training in infection control, within the health and safety section of their induction. Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good The homes’ recruitment practices aim to protect residents. Competent and qualified staff support residents. Staff members are provided with appropriate training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 Page 21 The manager confirmed that 50 of the staff team have achieved their National Vocational Qualification (NVQ). All new staff complete full induction training, which is completed within their first six months employment. Three staff recruitment files were examined as part of the inspection process. The files demonstrate that staff are being recruited correctly and all relevant checks with the Criminal Records Bureau (CRB) and against the Protection of Vulnerable Adults (POVA) list are being completed prior to appointment. Records show that two references are sought and that identity is confirmed. There were no gaps in employment history. There is now a training matrix in place, which shows that staff are trained in race and equality, health and safety, fire awareness, safe handling of medication, abuse awareness, manual handling, first aid, anti-discrimination, drugs awareness, care planning, whistle blowing and professional boundaries. One member of staff reported that they are still working through their induction book and has received training in mental awareness within this period. They added that they are “enjoying the work and feel that we get the opportunity to move people on”. Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good The manager is well run by a competent and qualified manager. Residents’ views are listened to and acted upon. They are involved in the development of the service. The homes’ health and safety policies and procedures aim to protect the residents. This judgement has been made using available evidence including a visit to this service. Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager of the home has a vast experience of working in Mental Health Services. She has a National Vocational Qualification (NVQ) level 4 in management and has achieved her Registered Managers Award (RMA). She is also an NVQ assessor and internal verifier for NVQ. There is ongoing training available to the manager and the team leader such as training in handling complaints. The manager reported that ‘Rethink’ are arranging for practice sharing forums for managers where they will discuss and share ideas on various subjects such as the National Minimum Standards. Residents confirmed that the manager is approachable and that they feel confident to raise any concerns with her. The manager confirmed that ‘Rethink’ carry out a quality audit annually and the outcomes are fed back to the manager. The organisation also completes a health and safety annual audit. Satisfaction surveys were sent out in 2006 to residents, families and healthcare professionals. The results of this survey can be found in the homes’ statement of purpose. The responses show that the service is considered to be of a high standard and 100 agree that residents are treated with dignity and respect. The manager and team leader explained that there is an expectation that residents attend the weekly residents’ meetings. This is to ensure that each person is aware of anything that may be happening within the home and also have the opportunity to raise concerns or put their point of view across. The home aim is to provide safe working practices to protect residents where possible. Staff members receive regular instruction in fire awareness and records show that fire drills take place every three months. The home has a fire risk assessment, which was updated on 3/2/07. Fire fighting equipment and testing of the emergency lighting took place on 17/2/07. The home has a current gas safety certificate and documentation to evidence that a check has been completed on all electrical portable appliances. Hot water temperatures are tested and recorded on a weekly basis to ensure they are safe. At the last inspection the inspector identified that there were toxic materials left in the bathroom, which should have been locked away. This has now been addressed. All accidents and incidents are recorded and forms are kept in residents’ case files in line with data protection principles. Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 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 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 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 4 4 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 3 X Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 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 YA20 Good Practice Recommendations It is recommended that the all staff members be reminded of the procedure for recording the refusal of medication on the MAR sheet. Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Herbert House DS0000028638.V330989.R01.S.doc Version 5.2 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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