Inspection on 07/02/06 for Imber House

This inspection was carried out on 7th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Imber House 20/11/08

Imber House 22/11/07

Imber House 04/05/07

Imber House 23/01/07

Imber House 06/09/06

Imber House 05/07/05

Imber House 03/03/05

Imber House 16/08/04

Imber House 15/03/04

Imber House 20/10/03

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Imber House 412 London Road South Lowestoft Suffolk NR33 0BH Lead Inspector Deborah Seddon Unannounced Inspection 7th February 2006 10:00 Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Imber House Address 412 London Road South Lowestoft Suffolk NR33 0BH 01502 500448 01502 500448 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) Mrs Patricia Lesley Webb Mrs Patricia Lesley Webb Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 2005 Brief Description of the Service: Imber House is a care home for five adults with learning disabilities. Male and female people are catered for from the age of 18 years upwards. It is situated on the main road in the south of Lowestoft on the border of Kirkley and Pakefield and is close to local shops, a bus route and is five minutes from the beach. It is a semi-detached building with accommodation on three floors. The residents occupy the ground and first floor whilst the owner and their family have bedroom accommodation on the second floor. The residents and the family share the kitchen, utility room and dining facilities. Three residents have bedrooms on the first floor and two on the ground floor. There is a garden and patio area for general use outside. Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced on a weekday afternoon and early evening lasting four and half hours. The inspection focused on looking at the standards not assessed at the last inspection on the 5th July 2005. Therefore to have a true reflection of the home this report should be read in conjunction with the report from the July inspection. On arrival the manager was out collecting two residents from day care services. The other three residents arrived home at different stages between 3.30pm and 4.30pm. A number of records were examined including those relating to residents, staff, training and policies and procedures. Time was spent talking with all five residents, the manager and staff. The inspector was shown around the home and was invited by residents to see their individual bedrooms. What the service does well: What has improved since the last inspection? What they could do better: Two staff files were seen at the inspection. All the relevant documents had been obtained with the exception of photographic identification for the maintenance person and the job application form for the other member of staff did not have a record relating to their past employment. Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 6 Death and dying is a sensitive issue. However to ensure that residents and their families wishes are dealt with respectfully and sensitively at the time of the resident becoming terminally ill, dying and death a record of service users wishes and feelings must be made in their care plan. 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. Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 Prospective residents can expect to have detailed information about the home before making a decision about where they live and to have a written contract between themselves and the home. EVIDENCE: The statement of purpose and service users guide was seen. Both documents contain detailed information about the service. A requirement from the previous inspection was for the aims and objectives of the home to be included in the statement of purpose. Evidence was seen that the aims, objectives and philosophy of the home had been added. The statement of purpose has clear guidance on how the home deals with referrals and admissions, stating residents can expect a three month trial period with a review to discuss if Imber House is the right choice of home. The most recent resident to move into the home was in October 2004. It was therefore difficult to fully assess standards 2,3, and 4. However information held in the resident’s file reflected that the manager had obtained a Suffolk County Council individual placement and had completed a new resident assessment form identifying the resident’s needs. This had been reviewed after 1 month and formed the basis of the resident’s care plan. Their individual placement plan referred to physiologist and psychiatric intervention in the past but required no support at present. Each resident had a copy of the service user guide in their care plan, which contained a copy of the contract terms and conditions of occupancy. Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10, Residents can expect to have care plan’s that identify their needs and support required, including behavioural management plans and risk assessments which support them to lead a positive and fulfilling lifestyle. Information held about residents is easily accessible and does not safeguard the confidentiality of the individual. EVIDENCE: The care plans of two residents were seen, each had a detailed assessment identifying their needs and the level of support required to enable the resident to maintain and improve their independence. These assessments were being reviewed on a regular basis. A requirement made at the previous inspection was for the care plans to be developed to reflect individual needs other than their personal care. Aims and objectives for each of the residents have been identified. For example one resident when moving into the home had limited domestic skills and an objective was for them to prepare their own breakfast. Evidence was seen in the care plan that the resident had been supported to meet this objective. Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 10 One resident is a member of Scope Society and is supported to participate in regular meetings. They have taken part in organised events by the group, for example they went on a trip to the London Eye and on a boat trip. A copy of the Lowestoft and North East Suffolk Scope newsletter was seen on the residents care plan informing them of forthcoming events. Residents are encouraged to participate in the running of the home. Residents were seen sitting around the dining room discussing issues about the day and preparing for the following day. They are consulted weekly on choice of food and take turns to assist in the weekly shopping. Residents spoken with were very clear about their choices of decoration in their personal rooms and the home. Regular residents meetings are held where they can discuss issues to do with day-to-day life in the home. Evidence was seen that residents are supported to manage their finances. One resident’s plan describes that they have learnt to manage their own money and has realised that if they save money during the week they have enough money to play pool and have a couple of beers on a Friday night. The risk assessment for another resident identified that they are encouraged to carry small amounts of money. The resident has limited knowledge of the value of money and is vulnerable whilst out in the community. The resident’s care plan showed that they have their own savings bank account and their relative acted as their appointee, managing the account. The resident is given an agreed amount of money by their relative on a weekly basis. One resident’s care plan had a behavioural management plan and risk assessment detailing the guidance and support the resident needed to integrate with the other people living in the home. Each of the residents has detailed assessments in place identifying risks and hazards when undertaking daily routines such as using public transport, helping with domestic tasks and preparing meals. All risk assessments were being reviewed on a regular basis. The home has a detailed policy and procedure in the event that a resident is reported as missing. Details were held at the front of each resident’s care plan, which has a description of the resident and a recent photograph for identification. Residents care plans are held in a cupboard in the dining room which all residents have access to, highlighting concerns around confidentiality of information. One resident was able to go to the cupboard and was seen putting the care plans of other residents away. Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12,13,14,15,16,17, Residents are supported to take part in appropriate activities within the local community and have the opportunity to mix with other adults. EVIDENCE: Day care facilities are tailored to meet the needs of the residents. One resident attends Gateway Club on a Tuesday and Thursday, Links Club on a Wednesday a Monday Club alternate weeks and a social club once a month. Another resident attends Yarmouth College and Yarmouth training centre during the week weekdays. They also help out at a stable in Yarmouth that offers work opportunities to people with learning disabilities where they help clean out the stables. The resident told the inspector they were going to start riding lessons. Another resident discussed with the inspector and the manager about their day care service closing. The resident wants to go to Yarmouth College, however the manager explained there was a problem around funding. The resident is funded by Norfolk and the Yarmouth College is based in Suffolk. Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 12 The manager is looking into the situation and has discussed with the resident the possibility of obtaining funding to provide a member of staff on a one to one basis to enable the resident to pursue activities of their choice, for example swimming, cooking. The home is on the bus route into the town centre, with a stop out side the home on the other side of the road. There are four pubs within walking distance providing a choice of food and opportunities to play pool or darts. There is also a fish and chip shop, two local shops, a bowling alley and sports centre providing a range of facilities for the residents. One of the resident’s has lived in the area for many years with their parents prior to moving into residential care. They have their own scooter enabling them to go out and about in the community and are well known around Lowestoft. Their surviving relative lives in a nearby residential home, where the resident is able to visit them on a regular basis. They both continue to attend activities in the community, for example Bingo. The resident has their own front door key and is able to come and go as they please. Friday night is residents night and they choose where they want to go. The home has a good relationship with the landlord of one of the pubs. They have access to the snooker room where they can mix with members of the public. They have a meal and play pool or snooker. Alternatively residents spend their time in the home with a take away meal and can if they choose, listen to music, watch television or videos in the privacy of their own rooms or in the lounge. Evidence was seen in one resident’s care plan that they enjoyed a holiday in Wales last year, a full detailed account of how the resident spent their holiday was included. Residents take turns to help with the shopping and domestic chores around the home. Evidence was seen that an agreed menu for the week had been made. If on the day the resident decides they do not want what is on offer the manager explained there are supplies of other foods in a well-stocked fridge and freezer. The menu seen included Chicken curry, sausage and mash, lasagne, cheese and potato pie and a Sunday roast. Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21, Residents cannot expect to be treated with sensitivity and respect regarding ageing, illness and death until they have had the opportunity to discuss and record their wishes. EVIDENCE: These standards were fully assessed at the last inspection with the exception of standard 21 and were found to be met with no shortfalls. A recommendation was made following the last inspection that when medication was not administered the code system was used to reflect this on the medication administration record (MAR) chart and not a signature. Evidence was seen that this is now taking place. The home has a policy for dealing with the death or dying of a resident. However there is no record on the residents care plans of their wishes of how staff need to deal with them getting older or in the event of terminal illness and death. A discussion took place with the manager that the residents and their families wishes should be discussed and recorded so that residents know that their wishes will be carried out with sensitivity and respect. Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23, People living in the home can expect be protected from abuse. However the home’s procedure for reporting allegations or suspicions of abuse needs to reflect the requirements of the Suffolk Policy and Procedure. EVIDENCE: At the previous inspection in July 2005 a recommendation was made for the manager to amend the complaints procedure to include an audit trail for complaints. The home’s complaints procedure was seen and has been changed to give clear details on how to make a complaint and to expect a response with 72 hours. The complainant is assured that their complaint will be resolved within 21 days and a record of the complaint will be logged. The procedure includes the contact details of the Commission for Social Care Inspection (CSCI). A requirement was made for the homes adult protection policy to be updated to reflect the Suffolk Policy. The manager has obtained a copy of Suffolk’s inter agency policy and each member of staff has been issued with a leaflet to read. However the home’s policy and procedure still needs to be amended to reflect the process of reporting allegations of abuse to the Customer First team as required by the Suffolk Policy and Procedure. Refresher training pack has been used to give staff information about the protection of vulnerable adults, which involves a video and a question and answer session. Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26, Service users can expect to live in a welcoming and well-maintained environment, which provides a good range of personal and communal space. EVIDENCE: Accommodation comprises of three floors. The ground floor has a kitchen (which residents use under supervision) a lounge with patio doors leading out into the garden, a dining room, two single bedrooms with sinks and a shared toilet and shower. The first floor has two single rooms and one double room, a separate toilet and a bathroom with shower and toilet. The third floor is the manager’s private accommodation. All rooms have television points and a washbasin. Doors to resident’s room are fitted with locks for privacy, if the resident wishes. Residents individually invited the inspector to see their bedrooms. These were nicely decorated and reflected the personalities of the residents. One resident had a signed picture of Daniel O’Donnell as well as other photos and pictures. Another resident had Manchester United and Arsenal football clubs memorabilia. Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 16 The washbasin in one resident’s bedroom has had a slow leak. This has now been repaired and refurbishment of their room is in process. New floorboards have been purchased and fitted. A new carpet, bedroom furniture and bed of the resident’s choice have been ordered. Another resident’s room is due to be decorated, they have also chosen new furniture and curtains. The homes décor is looking a little tired and worn which the manager has recognised and has employed a maintenance person to undertake a painting and decorating programme throughout the home. The lounge was in the process of being decorated during the inspection. The manager informed the inspector that a recent inspection of the gas appliances had taken place and the gas fire in the lounge had been condemned and was being removed the day after the inspection. A discussion took place between the manager and the residents about an alternative replacement to the gas fire. The home has a stair lift, which is currently out of order. None of the current residents use the stair lift. However the manager confirmed a new one has been ordered with a battery back up in case of power failure. Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35, Residents can expect to be cared for by a staff team who are supervised, supported and available in sufficient numbers to meet their needs. People living in the home can expect to be protected by the home’s recruitment procedures, although staff application forms must contain necessary information relating to their past employment. EVIDENCE: The manager and three permanent staff and a volunteer rotate to cover shifts across the week providing 24-hour care. There are two members of staff available at all times when the residents are at home. The manager formerly employed a deputy but they have recently left following some concerns about work related issues. The manager and a member of staff spoken with both confirmed that the atmosphere in the home has greatly improved and the residents appear much more relaxed. One member of staff spoken with has worked at the home for approximately four years. They work 18 hours a week and covers holidays and extra shifts if needed. They also work at the Anglia day centre nearby which two of the residents currently attend. They discussed their concerns about the closure of the day centre, which is moving to join with social services and the impact this will have on the residents. They spoke of feeling well supported by the manager and other staff and confirmed they have regular supervision and staff meetings. Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 18 The member of staffs file was looked at and all information relating to their recruitment had been obtained. However the job application form had not been fully completed with the staff’s employment history. Evidence was seen that staff training was taking place including an induction training record, refresher breakaway defence, and control and restraint applying the Unisafe techniques and basic life support through St Johns Ambulance. The member of staff told the inspector they also received training as a member of staff at the day centre, which included moving and handling and protection of vulnerable adults. Copies of certificates of training completed at day centre should be obtained and held on the staff’s file to give an accurate account of their training. A recommendation from the last inspection was for training records to be consolidated to give an overview of training needs and updates. The manager explained they had not yet completed this for all staff. The manager has recently employed a maintenance person through the crossing charity scheme helping unemployed people back into work. The scheme provides basic training such as moving and handling, health and safety and fire safety. The maintenance person’s file was seen and all recruitment checks had been carried out including references and criminal records bureau check (CRB). The only missing document was a photograph for identification, which the manager confirmed they would obtain. The inspector and manager discussed the new Skills for Care Common Induction Standards (CIS) for new employees. These standards replace the Sector Skills Council for Social Care (TOPPS) induction and foundation. Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41,43. Residents can expect to live in a home that is effectively managed and is run in their best interests. EVIDENCE: The manager has 15 years experience working with people with learning disabilities. They keep themselves up to date with current training and have completed the Registered Managers Award (RMA) at National Vocational Qualification (NVQ) level 4 in management and care. They run the business as a family home and have achieved a homely environment where residents appear to be happy and comfortable. Imber House has an effective quality monitoring system in place. A Feedback sheet is produced by the home and provided to day care services and relatives. Comments seen returned from the day service ranged from ”on arrival at day service the resident looked smart well-groomed”, “appeared jolly and enjoyed a joke with peers and staff”. “Staff are very friendly and helpful with any enquiries”. Another resident’s feedback sheet was less positive with concerns recorded about poor oral and personal hygiene. Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 20 The manager raised these concerns with staff at a staff meeting and the resident is now encouraged to shower every morning and on occasions sometimes twice a day. A subsequent feedback sheet made reference to the improvements in the resident’s hygiene. The feedback from one of the resident’s relatives was seen and had very positive comments about the residents care “My relative is very happy and settled at Imber House”, “their overall behaviour and disposition is very good”, “thank you to every one at the home” Residents are included in fire drills, which take place weekly. There are fire signs around the home directing to the fire exits and emergency lighting is fixed to walls. These are large switches in the form of a pad which when hit light up, providing enough light for people to see where to go to the exit. The home has a risk assessment and fire safety procedure in place. These documents have all been updated. The fire logbook was seen and was being kept up to date. There are extinguishers on all floors and smoke detectors with battery back up, which operate from the central system. There are fire exits on all floors. A Fire officer visited the home in December 2002 to inspect the home and on their recommendation the home had the cellar fire proofed. As already referred to in the Needs and Choices section of this report residents have access to the care plans and are involved in updating the information held about them. However they are not held in a secure place, which means other residents, and visitors have access to the personal information. The manager is in the process of updating all the home’s policies and procedures, a selection of procedures already updated in June 2005 were seen which included Control of Substances Hazardous to Health (COSHH), infection control and clinical waste and Reportable Injuries, diseases and Dangerous Occurrences Regulations (RIDDOR). A requirement was made at the last inspection for the manager to produce a business plan for Imber House. The manager showed the inspector a draft plan that they are in the process of completing with support of their solicitor. The manager will forward a completed business plan to the Commission for Social Care inspection (CSCI). The draft plan demonstrated that the home is running as a viable business and that the manager has plans to refurbish the home and provide wheelchair access. They are also committed to continually reassessing the needs of the residents to ensure that the home is providing a service that meets their individual needs. As part of their business plan the manager has produced an organisational checklist to ensure that they meet compliance with requirements of health and safety for example it demonstrates when the electrical certificate needs to be renewed and that the gas and central heating was serviced in January 2006. Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 21 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 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X 2 3 X 3 3 2 X 3 Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 YA41 YA10 Regulation 17 (1) (b) Requirement Residents care plans must be in a secure place to prevent other residents and visitors having access to confidential information A record of resident’s wishes and feelings must be made in their care plan and taken into account at the time of their death. Timescale for action 31/03/06 2 YA21 12 (3) 31/03/06 3 YA23 13 (6) 31/03/06 The home’s procedure must be developed to instruct staff on the procedure to follow when reporting allegations of abuse, to ensure they are referred to the Suffolk County Council’s Customer 1st team. Any gaps in employment records must be explored prior to the appointment of staff. 31/03/06 4 YA36 Sch 4 (6) (f) Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 23 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 YA35 Good Practice Recommendations Staff training records should be completed to reflect an overview of training that has taken place, training needs and training due. Copies of certificates for training undertaken outside of the home should be obtained and held on staffs file to provide an overall picture of training they have undertaken. Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Imber House DS0000024558.V281076.R01.S.doc Version 5.1 Page 25 - 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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