Inspection on 30/10/07 for Isabel Court Respite Care Unit

This inspection was carried out on 30th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Isabel Court Respite Care Unit 03/10/06

Similar services:

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Paradise Lodge

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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 Isabel Court Respite Care Unit Isobel Court Respite Care Unit 1-6 Isabel Court Walton Road Hoddesdon Hertfordshire EN11 0LQ Lead Inspector Sheila Knopp Unannounced Inspection 30 October & 12 November 2007 14:30 th th Isabel Court Respite Care Unit DS0000067470.V355037.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 Isabel Court Respite Care Unit DS0000067470.V355037.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. Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Isabel Court Respite Care Unit Address 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) Isobel Court Respite Care Unit 1-6 Isabel Court Walton Road Hoddesdon Hertfordshire EN11 0LQ 01438 737400 01992 904354 www.hertsdirect.org Hertfordshire County Council Cathryn Jean Sharples Care Home 3 Category(ies) of Learning disability (3), Physical disability (3) registration, with number of places Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd October 2006 Brief Description of the Service: Isabel Court Respite Care Unit for younger adults is a self-contained 3-bedroom ground floor flat within a purpose built development for younger adults. The spacious bedrooms have en-suite provision. Overhead tracking hoists are provided in two of the bedrooms and bathrooms. Service users have a lounge, kitchen diner and assisted bathing and shower facilities. There is a shared garden with patio areas and seating to the rear of the building. Hertfordshire County Council (HCC) runs the service. The building is owned and managed by Aldwyck Housing Association. It is in a residential area of Hoddesdon. Limited designated parking is available at the front of the building. Information about the service provided at Isabel Court can be obtained from the welcome pack and Statement of Purpose. These and a copy of the most recent CSCI inspection report can be obtained from the manager. Charges for the service are included as part of the total care package put in place by Hertfordshire County Council for each individual. Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This information in this report is based on two visits to the service. The visits, the first of which was unannounced, took place during the late afternoon and evening to enable us to meet the people who were booked in for overnight stays. We met the registered manager and four staff. Care records and records related to the running of the service, recruitment, training and health & safety were examined. We also looked at the information that we have received, or asked for, since the last key inspection on 3rd October 2006. This included the annual quality assurance assessment (AQAA) that was sent to us by the manager. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. We sent out survey forms to a sample of people using the service, relatives, and community health and social care professionals who have contact with the people using Isabel Court. A total of 27 survey forms were sent out and 12 have been returned. We looked at what the manager has told us about things that have happened in the service between inspections, these are called notifications and are a legal requirement. No requirements or recommendations have been made as a result of this inspection as we are satisfied that issues are picked up through Hertfordshire County Council’s (HCC) quality assurance systems and new guidance on care practices and health & safety standards are introduced as they become available. What the service does well: A person who stays at Isabel Court said ‘ I do like my time at the respite I like helping’. One person was asked what they would tell people about the service and they said ‘they (staff) take me out’. Two people were able to tell us they were comfortable during their stay. Sometimes they meet other people staying that they know, but they can go to their own room if they want to be quiet. Service users are invited to bring in homely belongings during their stay. Keys are available for them to lock things away and to have privacy in their room if they wish. Each bedroom has a TV and DVD player and there is a selection of viewing material to choose from. One service user had brought in their own DVDs to look at. A relative told us ‘ I am pleased with all aspects of care and attention my son receives’. Two relatives told us they were always made to feel welcome. One person said staff offer support and friendship. Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 6 Staff are knowledgeable about the needs of the people using the service and their families which means they are able to provide support and when the need arises respond flexibly to changes in arrangements or bookings. There is good communication between the staff, families and the community health and social care teams supporting the individuals who spend time at Isabel Court. This means staff keep up to date with any changes and are able to get help and advice to maintain the safety and well being of the people they support. A health care worker said ‘ the care service aims to provide the highest service. An excellent care team to work with’. Staff selected appropriate rooms for the people staying according to the specialist equipment and bathing arrangements they needed. On arrival people were made to feel welcome. Thought was given to their comfort in terms of drinks, snacks and perhaps the need to stretch and spend time out of their wheelchair before supper. Menus are planned with thought given to the people staying on particular nights. People enjoyed their meals on the days we visited. We have not received any complaints or concerns about this service between inspections. The people using the service can expect to be supported by staff they know. The staffing arrangements are flexible depending on the needs of the people using the service at any given time. There are very good auditing and quality control systems in place to check that the service is meeting the needs of the people who stay there and provides a safe environment for service users and staff. Staff have access to high quality training and are supported to develop their skills and obtain appropriate qualifications so they keep up to date with the care practices required to support the wide range of people who use the service. The staff came over as being a caring and committed team who take pride in what they do. What has improved since the last inspection? The information available to people about the service provided at Isabel Court contained in the Welcome pack and Service User Guide, is still being reviewed to make sure it is in an accessible and user-friendly format. Copies can be made available in different languages and formats. Liquid soap and disposable hand towels are now provided in appropriate areas to promote good hand hygiene. Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 7 Hot water temperatures are now tested regularly to check that the thermostatic mixer valves are working and accidents are prevented. A maximum/minimum thermometer has been made available so staff can check changes in the drug fridge temperatures more accurately. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Isabel Court Respite Care Unit DS0000067470.V355037.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 Isabel Court Respite Care Unit DS0000067470.V355037.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): Standard 1 & 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents can be assured that there is a long introduction period before people come to stay at Isabel Court so to make sure everyone is aware of the service to be provided and how the needs of each individual are to be met. EVIDENCE: People being introduced to the service have access to a Welcome pack giving them information about what to expect. Staff reported the documents are still being reviewed to make sure they are user friendly and accessible. It was reported that a Braille version of the Service User Guide had recently been provided. The manager’s Annual Quality Assurance Assessment (AQAA) stated they are hoping to provide an Italian version, as this is a prominent group within the local community. The care records examined demonstrated that staff had access to detailed assessments from the health & social care professionals involved with each individual in the community. A picture of the individual looking to use the respite service and their care needs is built up during contact with the person concerned, their families and visits to the service before an overnight stay is Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 10 booked. Individuals and their families are gradually introduced to the respite service so they build up the confidence required to spend time away from home. A senior member of staff spoke about arrangements to introduce a new young person to the idea of having respite stays and reported they had just received a request for a further stay after the initial visit. Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 11 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): Standards 6, 7 & 9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Each person staying for a short break can be assured that there is an agreed plan of care plan that tells staff how they need to be supported and any risks staff need to be aware of to maintain safety. People using the service can expect that the staff working in the service recognises and supports, and promotes the autonomy, dignity and privacy of each individual. EVIDENCE: A relative told us “they look after our relative well. They are happy to stay there and most importantly they follow their care plan at all times”. Detailed care plans involving service users, relatives and other health & social care professionals are put in place, as new people are introduced to the Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 12 service. Care plans and updated plans are agreed with the service user and or parent / carer as appropriate who are invited to sign them. Senior staff are part of the community multidisciplinary team that provides overall support and care for the individuals who stay at Isabel Court. They attend meetings and reviews, which enables them to keep the information held at Isabel Court on each individual, up to date. The staff interviews and care records examined, demonstrated that staff understand the practices and approach required to respect each person’s individuality, privacy and dignity. Examples of this are, consent given for listening devises or night checks were these are required to maintain the safety of the individuals concerned. Isabel Court Respite Care Unit DS0000067470.V355037.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): Standards 12, 13, 15, 16 & 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people who stay at Isabel Court can expect to be encouraged to spend time doing things they enjoy and increase their independence by being with people of their own age. Meals are arranged to suit the needs of the people who are staying and staff have had training to support people who have specific dietary needs or who require assistance to eat their meals. EVIDENCE: Each person’s care plan provides information about their interests, abilities and expectations. The staff on each shift organise events, activities and trips out according to the preferences of the people staying at any one time. Some individuals are able to join in events and trips taking place in the adjoining supported living accommodation. One of the young people visiting had brought Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 14 in DVDs to play and said sometimes they bring their playstation. Another person confirmed they liked to relax and be quiet after a busy day. There are opportunities to go out and about in the community with the support of staff. Senior staff said, while staff on each shift are responsible for organising activities, which may include trips out to the park, pub, shops, restaurant or bowling, they monitor what is taking place to make sure people are offered a range of experiences. There is good communication between the staff in the respite unit and day centres and colleges people attend during the day. This means if people are not feeling well or incidents have occurred during the day staff are aware of them. Staff were encouraging one person to have an extra snack, as they were aware they had not eaten much during the day. Staff were observed to be very supportive of one person who had arrived unexpectedly on the wrong day. They contacted this person’s parent to make sure they knew where the young person was and gently explained the mix up. The individual concerned was invited to tea and later taken home by a member of staff. Staff have food hygiene training and keep appropriate records to demonstrate that the food is stored and cooked in a safe and hygienic way. The weekly menu is planned according to the needs and preferences of the people staying each day. The manager’s AQAA stated that more service user involvement in menu planning and shopping is an area for further development. Packed lunches are prepared for them to take to their daytime activity. A range of drinks and snacks including fresh fruit were available for people to help themselves to. Individuals are able to make their own drinks if they can manage this safely. Staff cook the meals but report they provide opportunities for people to be involved in activities such as cake baking. One of the people having supper identified a member of staff as being very good at cooking Yorkshire pudding. Isabel Court Respite Care Unit DS0000067470.V355037.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): Standards 18, 19 & 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people using the service and their representatives can expect that the detailed assessment process and on going links with community health care specialists means that staff keep up to date and receive the training they need to look after people with a wide range of health care needs. Staff work to clear medication guidelines to make sure that the medicines people arrive with are appropriately labelled and have clear instructions so they can be given safely. EVIDENCE: Following the last inspection and a visit by the primary care trust pharmacist an amended medication procedure has been put in place to reflect current practice. A maximum / minimum thermometer is now available for staff to monitor changes in the drug refrigerator temperatures which may affect the safe storage of medicines. Detailed auditing procedures are put in place each Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 16 time anyone comes to stay so medication can be accounted for at all times. Staff receive training on the safe use of medicines and complete an assessment of their competency that includes six observed practice exercises before they can give out medicine on their own. Staff receive training in the administration of medicine used for emergency procedures. People who wish to continue to look after their own medicines would be provided with somewhere to lock their medicines away safely and supported by staff. Staff spoke of the training they had received. One person said they felt much more confident in managing the care of people with swallowing and feeding difficulties after training provided by a Speech & language Therapist. Staff also visit people in their own homes to familiarise themselves with how people wish to be looked after and specialist techniques are carried out. Isabel Court Respite Care Unit DS0000067470.V355037.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): Standards 22 & 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people who use the service are regularly asked for their views and can be confident any issues they raise will be dealt with in an open and positive manner. The organisations policies, procedures, recruitment procedures, staff training and close working relationships with partnership organisations protect service users from harm. EVIDENCE: To obtain the views of people using the service Hertfordshire County Council’s Customer Services department sends out ‘Have your say’ forms. This means people can give their views to an independent department. The information received is the summarised and passed on to the manager. The manager keeps a record of issues brought to the attention of staff together with details of the action taken and response given. Continued use and satisfaction with the service provided is also discussed as part of the care reviews that take place. Service users and their families are able to raise issues with a wide variety of professional workers. The formal complaints procedure sets out the response and timescales individuals can expect if they make a formal complaint and action they can take if they remain unhappy with the response. The action taken to resolve one concern from a relative had been fully addressed and recorded in the Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 18 complaint record. Nine compliments in the form of letters and cards had been received. The management team are up to date in relation to recent changes in the HCC multi-agency Safeguarding Adult procedures and updated training for staff will be made available. The records kept by staff demonstrate they understand the need to record and report changes in the physical or emotional state of individual service users, which may be symptomatic of wider concerns about their well being and safety. Issues in relation to equipment, which may be restrictive but are used for personal safety such as bed rails and wheelchair lap belts are clearly understood and supported by risk assessments. Staff keep records of the belongings people bring in with them to make sure personal items are not lost and any money or valuables can be accounted for. Isabel Court Respite Care Unit DS0000067470.V355037.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): Standards 24 & 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Each person who comes to stay can be assured that a suitable room is made ready for them. Adjustable beds, moving and handling equipment, bathing and toileting aids are available which means that people with very different needs in relation to their independence and mobility can be supported. The people who come to stay will find that everything is fresh, clean and hygienic. EVIDENCE: On both days we visited service users had been allocated rooms with appropriate equipment to meet their needs and risk assessments. Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 20 Two people who use the service were able to confirm their beds were comfortable. Personal items had been put out in their rooms to make them feel more familiar. A relative said, “The rooms are always clean and well maintained”. The manager identified in the AQAA that a quality assurance audit, which asked service users and staff about the environment confirmed people using the service were happy with the decoration, cleanliness and decoration of the unit. A tour of the premises confirmed that the fabric, furnishings and decoration of the unit are being maintained to a good standard. Teething problems with equipment, positioning of shower hoses and fixtures, following the opening of the unit, have been resolved as staff started to use the equipment with service users and requested modifications where required. Space to store equipment is limited. Laminated pictorial signs are used to indicate different rooms and their function. Pictures on the walls and in bedrooms help people to become familiar with their surroundings. There are appropriate systems in place for washing, clothing bedding and soiled linen, which meet current infection control standards. Staff have access to disposable gloves and aprons. Since the last inspection liquid soap and paper hand towels dispensers have been fitted in the ensuite bathrooms to promote good hand hygiene. Isabel Court Respite Care Unit DS0000067470.V355037.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): Standards 32, 34 & 35 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. An experienced staff team who have been checked for their suitability to work with vulnerable adults support the people who use the respite service. Staff receive regular training and opportunities to achieve additional qualifications relevant to the service provided within the respite unit. This means staff are regularly updating their skills and are aware of what is expected of them in terms of providing high standards of care in line with current practice. EVIDENCE: A relative commenting on the support they receive said, “The staff are just brilliant”. The interaction between service users and staff during both visits was observed to be positive, encouraging and good humoured. Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 22 The staff rota confirmed that staff work flexibly to meet the needs of the people using the service on particular days and nights. Staff have time to prepare the house before people come to stay and update care records. A high proportion of staff (80 ) have achieved care qualifications at NVQ level 2 or above. Senior staff are trained as NVQ assessors and have qualifications at NVQ level 3 & 4. Assistance and support is given to enable staff to achieve qualifications in a manner that suits their learning needs. There is a low turn over of staff and people using the service receive continuity and support from staff they are familiar with. A review of 3 personnel files confirmed that the required checks are carried out before staff are employed and have contact with service users. The records of the other staff were reviewed at the last inspection. If agency staff are required they are subject to similar checks by the agency Hertfordshire County Council (HCC) contract with and have an induction into the procedures, practices and expectations of staff working at Isabel Court. The manager’s AQAA stated that some service users had been involved in recruitment training alongside staff. The progress and development of staff is monitored through regular one to one supervision sessions and an annual performance and management review. Isabel Court Respite Care Unit DS0000067470.V355037.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): Standards 37, 39 & 42 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Isabel Court is run by a competent and experienced manager who is able to promote and develop the aims and objectives of the service There are excellent monitoring, auditing and quality assurance procedures in place to ensure service users are provided with a high standard of care, support and protection. The health & safety training, risk assessments and policies and procedures ensure that the safety of service users and staff is protected. Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 24 EVIDENCE: Mrs Sharples is an experienced manager who has worked for Hertfordshire County Council since 1990 in a variety of care settings. She has achieved the Registered Managers Award, which is the standard set for managers of care services. The home has a full range of policies and procedures to promote and protect residents’ health and safety. Staff receive the required statutory training to carry out their jobs safely. Records of safety checks and accidents and incidents are maintained. Advice is sought from other experts and agencies about health and safety issues, if further information is required. Checks on the hot water systems are now being recorded to ensure the thermostatic mixer valves remain in working order and accidents are prevented. The quality assurance systems in place include internal and external monitoring and verification of standards. The audit reports detail the action required to address any issues identified and the time scales for completion. The views of service users and key stakeholders are obtained. Specific care practice auditing standards, which are externally examined, are in place. An annual review of the service is carried out. The manager reported that this year they used the AQAA as a basis of their review. She has agreed to provide a copy of the report when it becomes available. The manager provided a detailed AQAA within the timescale requested. This report gave us clear information about the service and confidence that there is a continual process of review and development that puts the people who use the service at the centre of its’ activities. We can see through the monthly monitoring reports by a representative of Hertfordshire County Council that thorough review and monitoring processes are in place. Issues affecting the quality of the service provided to service users are picked up and addressed. Recent reports have identified the need to look at the management of service users files and ensure any signs displayed are appropriate and respect confidentiality. The records of routine servicing and maintenance of equipment and safety systems showed us that the required checks to protect the safety of service users and staff are being carried out. A report from the Hertfordshire Fire safety Department dated 26/4/07 confirms the systems in place meet current fire safety legislation. Staff have identified that cars from adjacent properties parked on the road outside one of the fire Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 25 exits may hinder the free passage of wheelchairs away from the building in the event of an emergency. This has been reported to the landlord for further review and action. Staff raised concerns about limited parking and the quality of lighting at the front of the building, which have been passed on to the manager. The organisations policies, procedures and information provided about the service reflect a positive approach to promoting equality and diversity, which includes the experiences of service users. Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 4 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 4 x x 3 x Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No requirements were made following 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. Refer to Standard Good Practice Recommendations Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Isabel Court Respite Care Unit DS0000067470.V355037.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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