Inspection on 05/08/05 for John Darling Mall

This inspection was carried out on 5th August 2005.

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

John Darling Mall 24/10/07

John Darling Mall 12/12/06

John Darling Mall 04/11/05

John Darling Mall 09/12/04

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

CARE HOME ADULTS 18-65 John Darling Mall Selborne Drive Eastleigh Hampshire SO50 4SE Lead Inspector Wendy Thomas Unannounced 5 August 2005,10:15 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 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 Stationary 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. John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service John Darling Mall Address Selborne Drive Eastleigh Hampshire SO50 4SE 023 8061 3101 023 8061 1497 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Hampshire County Council Wendy Frances Burkill CRH 24 Category(ies) of PD - Physical disability (24) registration, with number PD(E) - Physical disability - over 65 (2) of places John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two service users may be accommodated between the ages of 65 and 70 years. 2. One service user may be accommodated who has a sensory impairment. Date of last inspection 9 December 2004 Brief Description of the Service: John Darling Mall is a purpose built unit for up to 24 service users who have physical disabilities aged between 18 and 65. The service users are mainly there for short breaks or in preparation to moving to more independent living. There are, therefore, both long and short-term service users in residence. Assessment and rehabilitation facilities are also available. The building is single storey, split into three units with a central communal area and some smaller communal lounges. There is a central dining room, and each unit has its own kitchenette and dining area. John Darling Mall is close to local shops, pubs and other amenities that are accessible to service users. John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place between 10:15 and 17:15 on Friday 5 August 2005. On the day of the inspection there were nineteen service users in residence. During the inspection the inspector spoke with a group of seven service users and one service user on their own. The inspector had discussions with the manager, a senior residential service officer and a care assistant. The inspector toured the communal areas of the home and spent time examining records and procedures (medication and risk taking). The inspector did not meet with any of the long-stay service users, one of whom was away, two were attending a day service and others were spending time in their own rooms. Over the last year a review of the service, it’s strengths, weaknesses, the role that it plays in the lives of physically disabled people, and possible areas for future development has been carried out. The report is now in draft form and some of the proposed developments are starting to be implemented. What the service does well: John Darling Mall provides an environment where service users can come and stay secure in the knowledge that their physical needs will be met so that both they and their carers can have some respite from their home situation. One service user described the service as, “It’s great!” Another said that, “I haven’t found anything wrong with it.” The environment was designed with the aim of meeting the various different needs of a range of service users. It successfully manages to achieve this. Service users were happy with the quality of the staff, and when asked, agreed that needs were being competently met. The range of training courses that staff have attended means that within the team there is a lot of knowledge relating to meeting the needs of service users generally and those with specific conditions or disabilities. The home encourages service user involvement and feedback. All short-stay service users are given feedback sheets to complete following their stay and there is a service user group involved in discussions about the quality of the service and future developments. John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 2 Information is available to service users about the home so that they can form an opinion as to whether or not they wish to use the service. Improved pre-inspection assessments ensure that service users’ needs and aspirations can more readily be met during their stay at John Darling Mall. EVIDENCE: In discussion with the group of service users the inspector was informed that all were aware of the information booklets in their rooms containing information about the service (service users’ guide) and local amenities. One service user, who was staying at John Darling Mall for the first time, said that they had not been given any written information prior to their admission. They had, however, made a visit to the service and been shown round and given all the information they felt they needed verbally. The home does have a printed leaflet summarising the statement of purpose, which is usually given to enquirers interested in using the service. The need to make any necessary alterations to the service users’ guide and statement of purpose following the review of the service, currently being undertaken, was highlighted. The manager informed the inspector that there were plans underway to have a brochure for the service professionally printed. John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 Page 10 One service user spoken with was able to confirm that when they arrived for their current short break, they had been asked about any changes in their needs since their last visit, and whether any changes were needed to their support plans. The senior residential officer (RSO) who spoke with the inspector had been involved in redeveloping the pre-admission assessments as agreed at the previous inspection. These were found to be much improved. The senior RSO said that these were proving to be more useful and contained relevant and pertinent information and were a useful tool. John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9. The improved care plans completed for all long-stay service users and some short-sty service users provide good detail and enable staff to meet service users’ needs. Service users benefit from having their autonomy respected, with views on the running of the home being sought and incorporated into future plans for the service. Although the process of risk assessment is improving, service users are still being put at potential risk in that a number of risk areas have not been identified and management strategies drawn up. EVIDENCE: The senior RSO who spoke with the inspector had been involved in redeveloping the service user plans. She described how she had come up with the version that she felt was most appropriate to the service and service users. All the long-stay service users have had these more detailed care plans developed with them. They are a great improvement on the previous rudimentary care plans. The inspector also had a brief look at short-stay service users care plans. One of these was in the new format. Work still John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 Page 12 needs to be done to develop the more in-depth plans for all short-stay service users as they come in for their next stay. The service users who discussed this with the inspector did not feel that they were restricted in making their own decisions. As they lived at home independently most of the time they expected that their autonomy and selfdetermination would continue at John darling Mall. They felt that this was the case. There is a service user group who are involved in the decision-making processes for the service. The next meeting was planned for 16 August 2005. Service users’ views regarding the development of the service had been included in the draft of the review of the service seen by the inspector. Some progress had been made in risk assessing and risk management. The manager showed the inspector templates developed following specific needs with specific individual service users to cover such aspects as smoking, drinking, use of lap-belt, and going out. A new format had also been developed. Service users have risk assessments in relation to moving and handling, medication and one, two or three others. In looking through files and talking to service users the inspector became aware of other areas where individual service users would benefit from risk assessment e.g. one service user informed the inspector that they were looking after and administering their own medication, yet there was no risk assessment. The home’s procedures file included a risk taking policy that appeared to be a general Hampshire Social Services policy and although valid and pertinent in many ways did not outline the specific details of how risk assessment and management was being carried out at John Darling Mall. John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 16 and 17 Although some activity opportunities are now being offered, long-stay service users would benefit from more activities and opportunities for social, recreational, leisure, activities that are age, peer and culturally appropriate. Service users’ autonomy and independence is facilitated by staff respecting service users’ rights and the choices they make. A varied and balanced menu provides service users with a satisfactory diet. EVIDENCE: Following comments and requirements in previous inspection reports, the draft service review proposes providing more and planned activities and programmes for the longer-stay service users receiving the rehabilitation/reenablement service. The manager, service users and a member of staff all told the inspector about the start being made with an afternoon activity session once a week and the development of a resource-room where it was hoped internet access could be provided on the computers already installed. The inspector was informed that the staff involved in this were enthusiastic about the project. Another member of the care staff is currently training to drive the service’s minibus. This would mean that there was more scope to use the John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 Page 14 minibus during the evenings and weekends. The manager reported that keyworkers were now being allocated ten minutes a week to discuss activities or opportunities their key-service users would like. One of the senior RSOs was then responsible for fitting this into the rotas, in the fifteen hours made available each week to support such activities/opportunities. There is a clear commitment to improve the social, recreational, leisure and educational opportunities available to long-stay service users. The weekly bingo sessions and Thursday afternoon minibus trip continue for short-stay service users (if spaces are available long-stay service users may also attend these). With recent trips having been to a popular retail outlet, a boat trip, and pub lunches. If they normally attend the local day service they can choose to continue to do so during their stay along with some of the longstay service users who also attend some sessions. Whereas this inspector had been told by short-stay service users on previous inspections that they were satisfied with the level of activity, on this occasion the service users spoken with were virtually unanimous in declaring that they were bored at times and would like more activities and trips out to be provided. One said, “Thank goodness for word searches,” which a number of the service users enjoyed doing. Others were reading, chatting, or enjoying a cigarette together in the forum (common room) or mall. Service users appeared to be enjoying each other’s company with much friendly banter and mutual support. All service users spoken with stated that they would like the bar to be open more often. Volunteers operate this on Friday evenings. Most were not keen to go to the local pub. A member of staff said that few service users went out into the local community independently during their stays. One service user said that they would like to go over to the local shops but hadn’t been able to, as they needed a member of staff to push their wheelchair. Service users said that their rights were respected and responsibilities recognised. The inspector observed that staff allowed service users choice in determining what they did with their time in the home. When the inspector left the home the service users were enjoying their evening meal of shepherds pie and vegetables. There was arctic roll or fruit salad for dessert. After a long period of relying on agency staff the home has recruited a full-time cook. There were mixed views about the food from service users with some thinking it was fine, and one in particular finding it unsatisfactory. The rolling menus seen by the inspector provided a good choice of a variety of nutritional and balanced meals. John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 Service users’ personal support and healthcare needs were being met. Strengthening the medication and self-medication practices would reduce the risk to service users of incorrect administration. EVIDENCE: The service users spoken with were very complimentary about the staff, however the universal comment was that there were not enough staff and that some people were kept waiting a long time when it came to personal care needs in the morning. They acknowledged that on the whole someone responded promptly to their call-bell, but explained that as they were already attending to someone’s needs they would be back shortly. One service user said that on a previous stay they had fallen when transferring themselves from bed to wheelchair, fortunately they had been able to reach their call-bell, but they felt they had to wait a long time for a response (they said, ten minutes). Two service users described the changes from their routine at home as being difficult, as they both liked to be up by around 08:00 but the day of the inspection they had not been ready for the day until 10:20. One said that for this reason they had chosen not to have breakfast, as it would soon be lunchtime. John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 Page 16 The manager and inspector discussed the balance of realistic expectations and staff availability, as well as encouraging service users to communicate their wishes without feeling they were being excessively demanding. As in previous inspections, the staff confirmed that it could be very busy in the morning especially if there are a high number of service users requiring two members of staff to support them. Service users were asked if the staff spent time with them other then in response to their physical needs. Service users thought they were willing to but recognised that the staff were really busy and usually on the go. The manager described how one long-stay service user liaised directly with health care staff concerning their complex physical needs, and how they benefited from the specialist nurses they could liaise with regarding these. This person was very actively involved in managing their own healthcare. The inspector did not speak with this particular service user on this occasion, but a previous conversation corroborates this. The inspector read the home’s medication procedure. This explained the procedure in place and how staff were to apply it in good detail. It is recommended that the home consults the Royal Pharmaceutical Society of Great Britain’s guidance and revises the home’s policy sections on disposal of single doses and creating an audit of medication into and out of the home. Medication was appropriately stored and controlled drugs appropriately recorded. There were some omissions in the administration or recording of administration in the service users’ medication records. It was suggested that a system be created to ensure any such omissions are followed up more thoroughly. In the group discussion with service users one said that their medication was kept and administered by staff, another said that they kept and administered their own medication. The latter had not been informed about how to store their medication properly and therefore it was not secure. There was no risk assessment on the person’s files to demonstrating that that it was safe and appropriate for them to retain and administer their medication. John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 An effective complains procedure means that any service users’ concerns are followed up. Developing policies outlining how service users may be supported with financial matters will ensure that they receive the support and protection they need. EVIDENCE: All service users asked, were aware of the information booklets in their rooms. They were not aware that these contained the home’s complaints procedure, although they were keen to add that they had no cause to complain, and that if they did they would go to the office. The complaints procedure has been inspected on other occasions and was found to be satisfactory. The home’s complaints log showed one complaint. The complainant had found the home’s response unsatisfactory and was taking this through the Social Services complaints procedure. A letter from the complaints officer had been sent to the complainant following an investigation. The inspector had been told previously that the home did not take responsibility for service users’ money. Although true, on this occasion service users were observed to have locked cash tins provided by the home for the safe keeping of their cash and valuables. Although responsibility for their spending remains with service users, the keys to these cash tins are kept securely in the office. A policy is needed detailing this procedure and how service users access their money and what records are kept. It was noted that John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 Page 18 although all service users were reported to have been offered the use of a cash tin, not all chose to take it up. One service user described an agreement they had made with the staff regarding their financial situation and how to manage this. They found the arrangement satisfactory. This agreement was not, however sufficiently documented in their individual plan (Standard 7.5). Where service users make agreements with staff in relation to controlling their access to their property e.g. money, cigarettes etc. this should be clearly documented in the individual service user’s plan along with the rationale for this and who was involved in the discussions leading to the agreement. John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30. A well designed and equipped home, that is clean and hygienic meets the needs of service users . John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 Page 20 EVIDENCE: The home was purpose build twenty years ago and at the time it would have been quite innovative. It comprises of two rows of residential units incorporating independent flats, offices, kitchen and laundry linked by a covered mall, planted with trees and plants. The polycarbonate roofing has become stained and opaque, but still provides a pleasant environment beneath. Although quotes have been obtained to clean this it has been reported that Hampshire County Council have found these to be too expensive, and so the roof of the mall continues to look dirty, and light to be restricted. Within the complex, but independent of it are a number of flats provided by Raglan Housing association for people with physical disabilities. Staff at John Darling Mall provide a warden service to the tenants. The environment certainly meets the needs for which it was designed, being fully accessible to people with physical disabilities and having spacious bedrooms and communal areas. Although the residential service side of the building was designed as four smaller units, it operates very much as one unit. Most of the longer stay service users are accommodated in two of the units with the short-stay service users in the other two. However service users move freely between the communal areas of all four units. Community facilities and shops are nearby. The requirement that the seating in the lounges be replaced has been met. The lounges were not being used much during the inspection as the weather was good and service users preferred to be outside, in the mall, or in the forum (which is a smoking area). The inspector noted that the new chairs were a great improvement and more likely to meet the needs of the diverse service user group. The home employs cleaning staff and the communal areas and toilet and bathroom areas inspected were clean. Bedrooms were not inspected on this occasion, but service users found them satisfactory and said that they were comfortable. There were minor issues such as not being able to reach the light from the bed. Other service users said that their rooms had a bedside light so this was not a problem. One service user said that their bedside light did not work. Both were issues that can easily be remedied. Indeed the other service users suggested how to resolve this, with those who were familiar with service feeling confident to approach the handy-person to get this sorted. John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 The staff team’s ability to meet the needs of service users is enhanced by a wide variety of training experiences including introductions to conditions/disabilities that effect groups of service users. EVIDENCE: Staff training records showed that staff had had moving and handling training and the assistant cooks held basic food hygiene certificates. Staff across the team had attended a number of relevant courses including; adult protection, challenging behaviour, basic communication, understanding acquired brain injury, working with people who have had a stroke, management of continence, psychological effects of disability, advocacy/self advocacy, understanding the principles of care, scabies, introduction to multiple sclerosis, infection control, and training in relation to systems and processes used in Hampshire County Council services. The home has an annual two-day inhouse training where some of this information acquired through training courses is cascaded, speakers inform on specific issues such as Parkinson’ disease, there are updates on in-house procedures, such as care planning and risk assessing, fire training etc. The last such training session was in February 2005 and the inspector viewed the programme. The manager confirmed that 50 of the care staff are qualified to NVQ 2 or above which is in line with the recommendation in the National Minimum Standards. John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 Page 22 One of the senior RSOs is responsible for the training programme and staff are supported to go on Hampshire County Council training and several are currently doing or plan to start NVQs. The inspector spoke with a care assistant who had recently joined the staff team. They described their induction which included shadowing more experienced staff, one-to-one time with their line manager, time with the deputy manager finding out about the shift pattern and personnel matters, spending time with the administrator and with staff in the kitchen and laundry, time reading policies and procedures, and time with a senior RSO looking at health and safety. They said that they had found the induction useful and that other staff were helpful and they could approach them with any queries. John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42. The systems in place for service user feedback and consultation mean that service users’ views and opinions are taken into account in monitoring and developing the service. The mechanisms in place for checking, testing and servicing all plant and equipment ensure that staff and service user health safety are being well managed. EVIDENCE: All the service users asked had noticed the feedback sheet left in their rooms upon arrival. They informed the inspector that they usually completed these after their short-stays. They thought the questions were relevant and were satisfied with their input into the quality assurance mechanism. The manager has confirmed that there are eleven qualified first aiders, thus ensuring that there is always a qualified first aider on site. Almost all other staff including ancillary staff have completed and are up to date with emergency aid training. John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 Page 24 Although not verified by the inspector at the inspection, prior documentation completed by the manager stated that all fire detection equipment tests and services, gas equipment servicing, central heating servicing, electrical wiring checks, hot water temperature checks, servicing of specialist baths and hoists, and emergency call bell services were all being carried out at the required intervals, and a in-house health and safety audit was carried out quarterly in house. John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 2 x x x 3 3 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 John Darling Mall Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 Page 26 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 9 Regulation 13 (4) Requirement Timescale for action 4/11/05 2. 20 13 (2) 3. 23 17 (2) Schedule 4 (9) Areas of potential risk for service users must be identified and management strategies developed. Service users must be made 4/11/05 aware of the procedures they are expected to follow for the safe storage of any medicines they self-administer. A policy must be developed 4/11/05 regarding the support offered to service users in relation to the safekeeping of their money and valuables. 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. Refer to Standard 12 20 Good Practice Recommendations Continue to push ahead with developing more activities and opportunities for service users. It is recommended that the registered person consults the Royal Pharmaceutical Society of Great Britain’s guidance, “The administration and control of medicines in care homes and childrens homes” and makes any necessary adaptions to the homes medication procedure. H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 Page 27 John Darling Mall 3. John Darling Mall H54 S40678 John Darling Mall V243109 050805.doc Version 1.40 Page 28 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton Hampshire SO15 1GW 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. 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