Inspection on 11/06/07 for Highfield Road (5)

This inspection was carried out on 11th June 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Highfield Road (5) 15/08/06

Highfield Road (5) 19/12/05

Highfield Road (5) 23/11/04

Highfield Road (5) 10/05/04

Similar services:

Foxley Lane (121a)

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Highfield Road (5) 5 Highfield Road Purley Surrey CR5 2JJ Lead Inspector James O`Hara Key Unannounced Inspection 11th June 2007 09:00 Highfield Road (5) DS0000028115.V342590.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 Highfield Road (5) DS0000028115.V342590.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. Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highfield Road (5) Address 5 Highfield Road Purley Surrey CR5 2JJ 020 8660 6676 020 8660 1547 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) Surrey and Borders Partnership NHS Trust Post Vacant Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following category; 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 11 15th August 2006 Date of last inspection Brief Description of the Service: 5 Highfield Road is a residential home for adults with physical and learning disabilities, it is owned, managed, and staffed by the Surrey and Borders Partnership NHS Trust, a specialist health provider for people with learning disabilities. There are ten residential places at the home and one respite bed. Highfield Road is a large detached house located in a quite residential road in a quiet area of Purley and is well placed for access to Croydon and Purley town centres. The home has a large lounge, separate dining room, kitchen and laundry room. There is also a sensory room attached to the lounge. To the rear of the home is a large, well-maintained private garden, which is very popular with people who use the service in the summer months. Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced site visit was carried out between 9am and 1pm on a Monday morning/afternoon. Methods of inspection included a tour of the premises, observation of contact between the staff team and people who use the service and discussion with the home manager Ms Elizabeth Mahdi. A random unannounced inspection took place at the home on the 28th of February 2007. This report includes information from that inspection. Records examined included care plans, needs assessments, risk assessments, complaints, adult protection, training, medication, and health and safety. Requirements and recommendations from previous inspections were also discussed with Ms Mahdi. What the service does well: What has improved since the last inspection? Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 6 Ms Mahdi is in the process of being registered with the Commission For Social Care Inspection to run the home. The homes Statement of Purpose and Service Users Guide were updated in April 2007. People have had their care plans reviewed by their care managers. Peoples risk assessments are now reviewed in appropriate timescales and copies of the risk assessments are kept on file. The home is making good progress with person centred plans thus enabling people to express their wishes on how they are supported and make plans for what they want to do in the future. The home is developing systems so that communication between people and staff can be improved. Staff at the home receives regular supervision so as to ensure that people benefit from having a consistent approach to their needs. Following the Cornwall Enquiry the Surrey and Borders NHS Trust has developed a new assessment “The Cornwall Assessment”. The Cornwall Assessment is carried out at all of the Trust’s care homes as a way of evaluating the quality of the service provided. This process has taken place at Highfield Road and the home is awaiting feedback from the Trust. What they could do better: There were six requirements and eight recommendations set at the last key inspection. The requirements were assessed as met at the random unannounced inspection on the 28th of February 2007. As a result of this inspection there are two new requirements and four recommendations. The overall impression when visiting the home is that it is well managed. There have been a number of improvements made benefiting people who use the service and staff since the last key inspection. In general the arrangements for meeting the health care needs of people who use the service are good however members of staff who administer insulin should receive periodic refresher training on administering insulin. All members of staff should receive periodic refresher training on adult protection. The practice of wedging open the laundry room door should be eliminated. The inspector would like to thank people who use the service, Ms Mahdi and all other staff on duty for their support during this visit to the home. Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 7 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. Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 8 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 Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 9 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, 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides people who plan to use the service and their representatives with the information they need so that they can make an informed decision about whether or not to use the service. The homes admission procedure ensures that people would have a thorough assessment of their needs and aspirations before they move in. EVIDENCE: The home has a Statement of Purpose and Service User Guide. The Service User Guide includes all the necessary information specified in regulation 5 of the National Minimum Standards. These documents were reviewed and updated in April 2007. No new people have moved to the home since the last inspection. Surrey and Borders NHS Trust has its own assessment for admission to residential care, which is completed by the home. The fee charged at the home is £57,267,58 per annum. Highfield Road (5) DS0000028115.V342590.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 good. This judgement has been made using available evidence including a visit to this service. The home is making good progress with person centred plans thus enabling people to express their wishes on how they are supported and make plans for what they want to do in the future. The home is developing systems so that communication between people and staff can be improved. People have individual risk assessments and risk management strategies in place so that they can participate in activities in the home and in the community in a safe manner. EVIDENCE: A requirement was set at the last key inspection that people who use the service have their care plans reviewed by their care manager and that the issue of two people sharing a bedroom is discussed as part of their review. Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 11 At a random unannounced inspection at the home on the 28th of February 2007 nine peoples personal files were examined, all had a copy of their last care plan and there was evidence that their care plans had been reviewed. The issue of two people sharing a bedroom had also been discussed and recorded as part of their care plan reviews. The issue has been raised with and is under review with the Surrey and Borders NHS Trust. A requirement was set at the last key inspection that all people who use the service Person Centred Plans (service users plans) are kept under review. At the random inspection three peoples personal files were sampled. All had service users plans that had been reviewed. At the random inspection a member of staff stated that Croydons Person Centred Planning co-ordinator had visited the home to discuss Person Centred Planning with the home manager and the deputy manager. He had provided new formats and guidance for completing Person Centred Plans. During this inspection the deputy manager produced Person Centred Plans for all of the people who use the service. These included a completed health action plan, a My Plan and support plans. The My Plan included a communication profile. The deputy manager stated that the Croydons Person Centred Planning coordinator was due to visit the home the day after the inspection to see how the Person Centred Plans were progressing. It was previously recommended that the home manager contact the Speech and Language Therapy Department for advice on Total Communication. The deputy manager produced evidence that staff had attended training “Communication is more than a word” facilitated by the Speech and Language Therapy Team in March 2007. The deputy manager produced newly developed communication passports for one person and communication guidance for two other people. The deputy manager stated that work was ongoing to develop better communication between people and staff and visa versa. At the last key inspection the quality rating in this outcome area was assessed as poor however the home has made a number of significant improvements and further development could lead to the home achieving an excellent quality outcome at future inspections. A requirement was set at the last key inspection that all people who use the service risk assessments are reviewed in appropriate timescales and copies of the risk assessments be kept on their files so that the staff team and people who use the service are aware of the identified risks. Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 12 At the random inspection three peoples files were sampled. All files include risk assessments that had been reviewed and a date was set to review them again. The deputy manager and people who use the service key workers had signed the risk assessments. Highfield Road (5) DS0000028115.V342590.R01.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 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home could do more to ensure that a programme of activities is developed for each person. However people are being offered appropriate social and leisure opportunities to engage in both inside the home and in the wider community. Appropriate arrangements are made so that people have regular contact with their friends and families. Dietary needs are well catered for and well-balanced, nutritional meals, based on personal preferences are being prepared and offered to people who use the service. EVIDENCE: Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 14 It was required at the last key inspection that home manager review individual’s assessed needs; care plans and person centred plans and ensures that an individual programme of activities is developed for each person at the home. At the random inspection two peoples personal files were sampled at random. There was evidence that these peoples plans had been updated and had identified activities that these people would wish to attend such football matches, horse racing, swimming and long drives. However people did not have an individual programme of activities. Ms Mahdi stated that she has been liaising with a registered manager from another Surrey and Borders NHS Trust care home in relation to planning and recording activities that people attend. She stated that the registered manager was to send her a format that she uses in her service so that Ms Mahdi can develop an appropriate format for Highfield Road. The introduction of Person Centred Plans may help in further developing individual activities for people who use the service. Currently none of the people who use the service have employment. People attend Geoffrey Harris House day service, some in the morning and some in the afternoon. The home offers a range of recreational activities both in and outside of the home. People go out for lunch, cinema, clubs, shopping and bus rides. The home offers in house activities such as aromatherapy and also has sensory room. The home has two minibuses so it is usual that staff support people out into the community. The home encourages people to remain in contact with their relatives. There is an open visitors policy and the home just ask that visitors phone to ensure their family member is going to be in before they visit. Family and friends are invited to any social events held at the home as well as reviews. People can be visited in any of the homes communal areas as well as in their bedrooms. On the day of the inspection Ms Mahdi explained that two people had gone to Spain on holiday. One person had gone with a member of staff and the other had gone with their family. The homes menus are based on a four-week rota. The Surrey and Borders NHS Trust dietician checks menus for nutritional balance. People’s dietary and cultural requirements are reflected in the menus. Highfield Road (5) DS0000028115.V342590.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. This judgement has been made using all the available evidence including a site visit to this service. In general the arrangements for meeting the health care needs of people who use the service are good however members of staff who administer insulin should receive periodic refresher training on administering insulin. EVIDENCE: A requirement was set at the random inspection that the home manager ensure that procedures are in place for staff to follow in the event of individuals with epilepsy having seizures and when to administer PRN medication. During this inspection two pharmacists visited the home to offer advice on medication issues. This requirement was discussed. The deputy manager produced an epilepsy care plan for each person diagnosed with epilepsy. The deputy manager stated that these plans had been on file for some time, the plan was not dated. The epilepsy care plan included a description of typical seizures, guidance for staff to follow i.e. when to call an ambulance, a rectal diazepam treatment plan and a seizure chart. The deputy manager wondered why this plan had not been produced at previous inspections. Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 16 It was agreed by all that these plans where appropriate however needed to be reviewed and updated. It is recommended that people’s epilepsy care plans are reviewed and updated. The deputy manager also stated that the practice manager from the General Practitioners surgery visited the home recently and completed health checks for all of the people who use the service. One person who uses the service is diabetic. The Specialist Diabetic Nurse has delegated the responsibility for the administration of insulin to staff at the home. The Specialist Diabetic Nurse trained a number of staff on the administration of insulin in 2004 and 2005. It was recommended at the last key inspection that staff have periodic refresher training on the administration of insulin. At the random inspection a member of staff stated that she had arranged for staff to attend training on the administration of insulin on the 8th of March 2007. During this inspection the deputy manager stated that the Specialist Diabetic Nurse that was to train staff, cancelled the training. The registered manager must ensure that all members of staff who administer insulin receive periodic refresher training on administering insulin. Highfield Road (5) DS0000028115.V342590.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. This judgement has been made using all the available evidence including a site visit to this service. The home has an appropriate complaints procedure in a number of formats so that people who use the service can understand. The home has suitable vulnerable adult protection and abuse prevention measures in place so that people are so far as reasonably practicable protected from abuse. EVIDENCE: Ms Mahdi stated that there had been no complaints made to the home since the last inspection. Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 18 At the last key inspection Ms Madhi provided evidence that all staff had attended training on adult protection. Some members of staff attended training in October 2004, October 2005. It was recommended that all members of staff have periodic refresher training on adult protection. Ms Mahdi produced evidence that the deputy manager had written to Croydon Council for training on adult protection. Ms Mahdi stated that the home had yet to have a response. It is recommended that all members of staff receive periodic refresher training on adult protection. Ms Mahdi stated that the Trust was in the process of reviewing its policy and procedures. The Surrey and Borders NHS Trust has a Whistle Blowing Policy. It is recommended that the Surrey and Borders NHS Trust Whistle Blowing Policy be discussed with staff at the next team meeting. Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 19 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. This judgement has been made using all the available evidence including a site visit to this service. The overall impression when visiting this home is that it is well decorated, homely, comfortable, clean and hygienic however the practices of wedging open the laundry room fire door could leave people at risk. EVIDENCE: On the day of the inspection the premises was clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. The home has five toilets and two baths. One of the baths is suitable for people with mobility problems. The bathrooms are situated close to people’s bedrooms and communal areas. The toilets and bathrooms were clean and in good working order. Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 20 The home has a spacious lounge, which was large enough for people to sit together if they wish. The dining room area is domestic in nature and contains suitable tables and chairs. There is also a sensory room just off the lounge area that is fully equipped and used to run aromatherapy and sensory sessions for people who use the service. There are laundry facilities with a sluice and an industrial type machine, which is capable of washing at high temperatures. It was observed that the fire door leading to the laundry was wedged open and coat hangers hung on the release mechanism. The registered manager must ensure that the practice of wedging open the laundry room door is eliminated. It was observed that the ceiling in the hallway landing had water damage. Ms Mahdi stated that maintenance staff had fixed a leak in the roof and there were plans to repaint the ceiling when it died out. The Surrey and Borders NHS Trust provide maintenance for the home on an as required basis. Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 21 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 and 36. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The homes procedures for the recruitment of staff appear to be robust and provide the necessary safeguards to ensure that so far as reasonably practicable people who use the service are not placed at risk of harm or abuse. Staff at the home receives regular supervision so as to ensure that people who use the service benefit from having a consistent approach to their needs. EVIDENCE: Ms Mahdi stated that no new members of staff have started working at the home since the last inspection. The Commission has seen all current staffs Criminal Records Bureau Checks. Ms Mahdi produced a staff training analysis for the home. Ms Mahdi stated that this was completed at the request of her line manager in order to identify the training needs of the staff team. Ms Mahdi explained that the staff training analysis has been passed to the Surrey and Borders NHS Trust training department in order that training can be arranged for staff. Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 22 Training needs identified in other areas of this report are; Members of staff who administer insulin should receive periodic refresher training on administering insulin. All members of staff should receive periodic refresher training on adult protection. The Trusts Whistle Blowing Policy should be discussed with staff at the next team meeting. A requirement was set at the last key inspection that all members of staff receive supervision at least six times a year. At the random inspection a member of staff produced recorded evidence that all members of staff are receiving regular supervision at the required frequency. Ms Mahdi produced evidence that all staff are undergoing the Surrey and Borders NHS Trusts appraisal system “Knowledge and Skills Framework”. Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall impression when visiting the home is that it is well managed. There have been a number of improvements made benefiting people who use the service and staff since the last key inspection. EVIDENCE: A requirement was set at the last key inspection that the Surrey and Borders NHS Trust ensure that the home manager is registered with the Commission For Social Care Inspection to run the home. Ms Elizabeth Mahdi is currently in the process of being registered with the Commission For Social Care Inspection to run the home. Copies of monthly Regulation 26 Visit reports were available in the home for inspection. The deputy manager was advised that it is no longer a requirement Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 24 that copies of Regulation 26 Visit reports be sent to the Commission however the home should make the reports available for inspection. Ms Mahdi stated that the Surrey and Borders NHS Trust had sent questionnaires to people who use the service and their relatives for feedback about the service. She stated that people had been supported to complete the questionnaires at the day service and these had been sent back to the Surrey and Borders Information Department for analysis. Ms Mahdi stated that the home is awaiting feedback from the Information Department. Ms Mahdi stated that following the Cornwall Enquiry the Surrey and Borders NHS Trust had developed a new assessment “The Cornwall Assessment”. Ms Mahdi stated that home managers had been asked to complete “The Cornwall Assessment” for their service and hand it to the Trust. Home managers were then given a copy of an assessment from another service. They then made arrangements to work a shift in that service and evaluate that services Cornwall Assessment and feedback their findings to the Trust. Ms Mahdi stated that this process had taken place at the home and she is awaiting feedback from the Trust. It was recommended that staff date the receipts when the works department carry out testing or other maintenance work at the home. At the random inspection the receipts for when the works department carry out testing or other maintenance work at the home were examined; these had been signed and dated by staff. Ms Mahdi produced evidence that Portable Appliance Testing had been carried out at the home but did not have a certificate, a Landlords Gas Safety check had also been carried our 03/05/07 and Legionellas Testing had been carried out in 23/06/06. Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 3 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 2 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 3 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 3 2 X 3 X 3 X X 3 X Highfield Road (5) DS0000028115.V342590.R01.S.doc Version 5.2 Page 26 No. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 (2) Requirement The registered manager must ensure that all members of staff who administer insulin receive periodic refresher training on administering insulin. The registered manager must ensure that the practice of wedging open the laundry room door is eliminated. Timescale for action 31/08/07 2. YA24 13 (4) c 12/06/07 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. 2. 3. 4. Refer to Standard YA20 YA23 YA23 YA12 Good Practice Recommendations It is recommended that people’s epilepsy care plans are reviewed and updated. It is recommended that all members of staff receive periodic refresher training on adult protection. It is recommended that the Surrey and Borders NHS Trust Whistle Blowing Policy be discussed with staff at the next team meeting. It is recommended that the home develop an appropriate system for recording the actual daily activity attended by individual service users. DS0000028115.V342590.R01.S.doc Version 5.2 Page 27 Highfield Road (5) Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. 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