Inspection on 12/10/06 for Highbury House

This inspection was carried out on 12th October 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

Highbury House 11/09/07

Highbury House 07/02/06

Highbury House 19/05/05

Highbury House 20/10/04

Highbury House 04/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Highbury House 207 Outland Road Peverell Plymouth Devon PL2 3PF Lead Inspector Kim Fowler Key Unannounced Inspection 12th October 2006 09:30 Highbury House DS0000003519.V306827.R02.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 Highbury House DS0000003519.V306827.R02.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. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highbury House Address 207 Outland Road Peverell Plymouth Devon PL2 3PF 01752 753710 01752 796299 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) Plymouth Highbury Trust Mr Ian Philip Oliver Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Age 18-65 Three named Service Users over the age of 65 Service Users with a Learning Disability, some of whom may also have a Physical Disability. 7th February 2006 Date of last inspection Brief Description of the Service: Highbury House is a care home providing personal care and accommodation for nine people with learning disabilities. It is owned by the Plymouth Highbury Trust, which is a voluntary sector organisation, and affiliated to the Royal Mencap Society. This home is located in the residential area of Peverell, close to shops, pubs, the post office and other amenities. The home was opened in 2000 and is situated on the 1st floor of a building on the site of the Plymouth Mencap Society, where there is also another care home and a day centre owned and managed by the Society. There are stairs and a shaft lift available. The ground floor of the building is used by the Local Authority to provide a day service for adults with learning disabilities and there is a separate entrance. All the homes bedrooms are single and none of them have en suite facilities. There are separate lounge and dining rooms and the home has a call bell system throughout. The home has an attractive patio and garden accessible to all the service users, shared with the other facilities on the site. The home is staffed 24 hours a day; there are 2 care staff sleeping in at night. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit of this inspection took place over 1 day. The Registered Manager, who is presently on secondment working elsewhere in Mencap, and the acting manager were available during the inspection. The inspector made a tour of the building and spoke to the residents and one visitor visiting at the time of the inspection. Documentation relating to the care planning process and the management of the home were examined. Prior to the inspection, resident comment cards had been sent to the care home to allow residents to comment upon their experiences. Four service user cards, four staff surveys, one Health Care Professional and four relative feedback cards were returned to the Commission. All comments raised are in the relevant area of the report. What the service does well: What has improved since the last inspection? What they could do better: At present, the service is operating without a registered manager. It was agreed that the registered manager could be absent for 3 months on a secondment. Unfortunately the manager has now been absent for 5 months, and the Commission has not agreed to this. Service users would feel more confident in the management of the service if a registered manager were available on site. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 6 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. Highbury House DS0000003519.V306827.R02.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 Highbury House DS0000003519.V306827.R02.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective new service users can be assured that the home will complete a detailed pre-admission assessment that will assist staff to meet their individual needs. EVIDENCE: This home has not admitted any new service users for 5 years. Discussion with the service’s managers showed it is clear they are both aware of the home pre-admission procedure. This procedure is based on person centred planning to ensure any prospective service users are suitable for admission to the home, and that the home is the right one for them. The admission process also includes taking a full history and assessment of needs ensuring that the care needs of the service user can be met by the home. Pre-admission information would also provide information for service users individual care plans. This information is important so that prospective service Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 9 users are assured that their health care needs can be met as well as their physical needs. Highbury House DS0000003519.V306827.R02.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): 6/7/9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users at Highbury House are encouraged and supported to make decisions about their own lives so that they can maintain their independence. EVIDENCE: The service user files that were examined showed that each service user has a comprehensive service user plan in place. This included full details of any treatment and rehabilitation currently being provided. These care plans ensure that staff are aware of service users’ needs and so will promote the consistency of care delivery. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 11 Details contained in these plans showed that the service users and their families were involved in the planning and review of care whenever possible. Some files showed that some Care Managers also attend yearly reviews. All specialist input including Occupational Therapist and Physiotherapist had been recorded in case files. Case file information describes that one service user has agreed that restrictions are placed on how their personal allowance is spent, as part of a therapeutic care regime. The document was signed by the manager of the home and by the service user. Intervention programmes are described in detail. These can be used if a service user’s behaviour becomes challenging. Each file examined named the key worker for each service user. The service users are encouraged to make decisions on everyday issues. The home uses a local advocate service when possible. The advocate service is regularly involved with the home and has attended review meetings on request. All four service users surveys stated that they “Do what they want”. One went on to say they could go to bed and get up when they want. Clearly recorded is how and who manages individual service users’ money. The files show that finance information is kept separately from files that contain information about care provision. The finance files showed what money each service user received and from what source. Bank account details are also held in each finance file. Several service users’ money was checked during this inspection and was correct, as cash balanced with financial records. Each service user file examined contained a full comprehensive risk assessment. These risk assessments are based on everyday activities that encourage independence. Any action required to minimise risk, including input from the falls clinic, is clearly recorded onto individual files. These ensure the safety of both staff and service users. This information is important to minimize further risk. Information held on files is used to promote the respect, privacy and dignity of each service user in the home. All service users spoken with about meals, menus and food in the home confirmed that this was satisfactory. Some service users assist with the preparation of the meals. Participation in planning the home’s menus was confirmed and several service users stated they have been shopping for food. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 12 Many of the service users spoken with felt that the food was varied and they had a choice particularly if the meal for the day was not to their liking. Observation during a mealtime confirmed that a service user had received a different choice of food than was on offer. All service users have staff support and specialist equipment, if required, to promote independence at meal times. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. 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 this service. The service users in this home can be confident that the home will promote and provide support for them to access the local community and leisure activities. This promotes the service users’ independence. The service users confirmed the home provides good choice of food that is of good quality and wholesome. EVIDENCE: The service user files examined during the inspection showed that two of the service users had paid employment. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 14 During the case tracking process these two service users were spoken with and confirmed the details of the work they carry out. Two other service users attend college via day care services. The service users confirmed their attendance and the life skills courses presently being undertaken. These colleges are open to the general public promoting community links and social inclusion. The manager informed the inspector that three service users are due to start at a local school for art and craft sessions and another service user attends a theatre group. All the service users were spoken with during this inspection and some gave details of the day care or places they attend. All service users access the local community including visiting the local shops, theatre and main town. Files that were examined showed family involvement. Four family and relative feedback cards were received at the Commission. One card held the comment that their relative was not always able to attend their day placement due to staff shortages. Another card commented that the relative has the highest regard for the home. All service users spoken with during this inspection said that they either have family or friends that visit the home or they go out to visit them regularly. One service user said they go on holiday with their family. The staff promote independence as much as possible and this was evident when observing interaction between staff and service users. The service users are able to access all parts of the home and help with domestic tasks. All individual files contained a list of domestic tasks undertaken by each service user. Each task is supported by written risk assessments. The service users preferred form of address was recorded onto individual files and one service user spoken with confirmed that this was their choice. Three staff surveys were returned to the Commission. One stated, “Residents were very happy and secure at home. Another went on to say, “The staff and service users have really good relationships, where the service users take an active part in the running of the home”. The third said, under the anything the care home does really well, “ Residents are encouraged to be individuals and express themselves”. Highbury House DS0000003519.V306827.R02.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): 18/19/20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can now be confident that the home’s medication recording system will protect them from risk, and staff provide good personal support promoting privacy and dignity at all times. EVIDENCE: The home’s service user care plan files showed that personal support is well documented for each service user. These were supported by risk assessments when necessary. This ensures that staff are aware of service users needs and will promote consistency in care. Many of the service users spoken with were able to confirm that the staff provide excellent personal care. Many of the service users agreed that the staff provide all personal care in private and promote their dignity and privacy at all times. Several service users stated that they are able to make choices about what time they go to bed and get up in the morning. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 16 All the service user feedback surveys received by the Commission stated the times of going to bed and getting up were flexible. Some service users were observed with the technical aid they required and this included a hearing aid and a wheelchair. This ensures that service users’ physical needs are met and that specialist equipment is provided. Specialist assessments were recorded in care files providing additional information for staff on the safe manual handling of service users. Each service user has a designated key worker and each service user has their likes and dislikes recorded on each care plan. The home has an advocate service available who calls into the home and was interviewed as part of this inspection. Each service user is having a Healthcare Action Plan developed. Two completed files were examined as evidence. These files aim to be taken with each service user when visiting other agencies. The manager stated that one service user who recently attended a day surgery appointment at the local hospital had taken this file with them. This file was used by the hospital staff to aid communication and also provided information on current health needs and medication to promote service users independence. These files also support service users to facilitate and take control of and manage their own health care needs. Information is recorded onto service user files if any service user has any involvement with other professionals including dentist, chiropodist and hospital outpatient appointments. The medication system was checked during this inspection. The control drugs were held in an appropriate cupboard and were checked and correct during the inspection. Staff had not signed for several items of medication that had been administered. Some medication had had a change of dose and this change had not been signed or dated. One change in medication had not had the change in dose clearly recorded. This could cause service users to receive the wrong dose. Two amounts of medication were found in the drug cupboard and were not accounted for. The system put in place to use this medication lead to confusion and could lead to service users receiving the incorrect doses. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 17 A new medication procedure had been written. The staff meeting minutes showed that this had been discussed at a recent staff meeting and staff were asked to sign the new procedure to ensure that the staff understood and followed this. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 18 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): 22/23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users can be confident that any complaints or concerns raised will be listened to, acted upon and well managed by the home. EVIDENCE: The home has a complaints procedure in place and is clearly displayed on the home’s notice board. This information included how to contact the CSCI and the process of how a complaint is dealt with, including timescales. This information enables everyone to know how complaints are managed. The Commission have not received any complaints. Evident on one file was that an internal complaint received was dealt with within the given timescales. Also recorded was the action taken and all correspondence held in connection with this complaint. Some of the service users spoken with confirmed that they were aware they could make a complaint and they would approach the management or staff of the home if they had any complaints or concerns. Several staff stated during interviews that they felt that all service users views were listened to and acted upon. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 19 The manager is due to complete the investigators training in the near future. This is training provided by Plymouth Social Services that enables senior care workers to have the knowledge and confidence to investigate complaints within the service they work. The management informed the inspector that some of the staff had completed the Plymouth Adult Protection training. Discussion with some of the staff confirmed they were aware of the adult protection process and the content of Plymouth’s alerters guide which give clear information about how to recognise that abuse may have occurred and how to report it. Of the four service user surveys returned to the Commission three stated that they would know who to make a complaint to. One said No, but that they would speak to the manager or acting manager. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 20 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): 24/30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users benefit from a homely, comfortable, clean and well maintained building that meets their needs. EVIDENCE: The home is well kept, safe and accessible for all service users currently living at the home. The home employs their own maintenance person who carries out regular everyday repairs. The house was found to be warm, bright and well decorated. The furnishing and fittings were of a good quality and domestic in character. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 21 The premises were clean hygienic and free from offensive odours. Laundry facilities were separate and a sluice was available. One staff member is responsible for infection control and some staff had completed an infection control course. All the bedrooms that were inspected were well decorated and had been personalised to meet the tastes of the service users. The management and staff stated that the service users are offered a choice when their room is repainted and one service user confirmed their involvement in choosing a colour scheme. All the bathroom and toilet doors are fitted with a lock that can be overridden from the outside maintaining both the privacy and safety of the service users. A good quality of living environment gives the residents a better quality of life. One staff survey received by the Commission said, “The care home fosters a homely environment, which is very distinctive and is often commented upon by visitors”. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 22 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): 32/34/35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by well-motivated and caring staff in sufficient numbers to meet the needs of those currently living at the home. Recruitment practices protect residents. Staff training, supervision and appraisals are carried out regularly to all staff to ensure that all assessed needs of service users are met. EVIDENCE: The staff interviewed felt that the home had sufficient staff on duty; one felt additional staff at weekends would benefit service users. The staff were seen throughout the inspection to be relaxed, patient and helpful when assisting the service users. The service users spoken with confirmed that staff are available and at times extra staff are made available when trips or holidays are organised. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 23 Of the three staff surveys returned to the Commission all three stated that “ more staff” would benefit service users. Information gathered from the pre-inspection questionnaire shows that 33 of the home’s staff hold a NVQ at level 2 or above. The pre-inspection questionnaire stated the completion of Criminal Records Bureau (CRB) clearances had been achieved for all staff. The management of the home confirmed this information. Personnel records were available in the home to verify the recruitment procedure carried out for each member of staff. Examination of staff files showed that all bar one staff had the required preemployment checks in place ensuring, as far as possible, that unsuitable staff are not employed. Only one reference was available for one staff member. Several staff confirmed that they had received regular supervision. This included one service user employed by the home to carry out domestic duties. The staff files examined showed that staff had regular supervision and staff confirmed they had completed staff Appraisals. Minutes were seen of the recent staff meeting. Regular consultation with staff ensures staff can contribute to the running of the home and are aware of the home’s aims and objectives and philosophies of care. This promotes consistency and improvement. Some staff training records showed that this was ongoing and regular. Most of the staff interviewed confirmed completion of courses on Medication training, Health and Safety and Manual Handling. Information was recorded that several staff members were booked on a Person Centred Planning course. Staff files showed that certificates were in place for some staff that had completed the Adult Protection training. A thorough training programme is run by the home to ensure that the level of qualification of the staff in the home is maintained. The staff team are trained and competent to deliver care. One staff member file showed that they had completed an Induction programme and another staff member confirmed they had shadowed other staff on duty until the completion of their Induction training to ensure the staff had confidence in the care delivered. One Health and Social Care professional’s feedback card was sent to the Commission. This card stated, “Staff appear appreciative of my team’s time, commitment and the recommendations which we suggest. My overall impression is of a team that work well together who try to support all the residents appropriately in a friendly and person centred way”. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 24 One staff survey stated “ The staff team have an almost family feel as we socialise together and support each other, this has been beneficial to the service users as it results in a safe, relaxed atmosphere”. All four service user surveys stated that the staff “always” treat them well. One said, “they are good to me”, another said, “They always treat me very well. I do not want to move anywhere else, I am happy”. One stated, “They (the staff) are very helpful and try to sort out any problems”. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 25 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): 37/39/42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although the registered manager is absent from the home at present, the acting manager is doing a good job and service users can feel confident that their needs will be met. EVIDENCE: The Registered Manager of the home is currently on secondment and due back within 2 months. The Registered manager was available during the inspection and has regular contact with the home. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 26 Quality Assurance surveys are available and these include surveys for families, friends and service users. These surveys have not been updated since May 2005 and require updating to ensure that all visitors, service users and families are able to give feedback. Sampling of records indicated equipment is serviced regularly and maintained in good order. This included hoists and the lift. Staff have regular training from a local college on Manual Handling. Other courses completed include Health and Safety, First Aid and Infection control for the protection of both staff and service users. The fire log showed regular fire alarm testing took place providing evidence that staff are competent in this area. Accidents are recorded in detail and reviewed; this enables staff to identify any risks to service users or changes in their health. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 27 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 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 4 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 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 4 2 X 3 X 3 X X 3 X Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 28 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 All medication should be signed for. All changes in medication should be clearly written, dated and signed by the staff member. All medication must be accounted for. 2. YA39 Quality Assurance surveys should be undated. Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Highbury House DS0000003519.V306827.R02.S.doc Version 5.2 Page 30 - 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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