Inspection on 07/06/07 for Laural House

This inspection was carried out on 7th June 2007.

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

The inspector 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

Laural House 06/06/06

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

CARE HOME ADULTS 18-65 Laural House 15 Fairbourne Road London N17 6TP Lead Inspector Brian Bowie Key Unannounced Inspection 7th June 2007 09:00 DS0000064230.V336932.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 DS0000064230.V336932.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. DS0000064230.V336932.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Laural House Address 15 Fairbourne Road London N17 6TP 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) 020 8801 0242 020 8808 3748 akwahouseltd@aol.com Akwa House Limited Mr Alexio Kadira Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places DS0000064230.V336932.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2006 Brief Description of the Service: Laural House is a small care home for 4 adults with mental health needs. It is run by Akwa House Ltd which runs 2 other homes for people with mental health needs. The proprietor and registered manager is Alex Kadira who is a qualified mental health nurse. Laural House opened in March 2006. The home is situated in a residential road off Philip Lane in Tottenham. It is close to shops and public transport. Each bedroom has en-suite facilities. There is a lounge and separate kitchen dining area on the ground floor with a small garden at the rear of the property. The home’s brochures states the aim of the service is: ‘To build a therapeutic relationship and work in partnership with clients to enhance their quality of life to its optimal level, thus empowering them to live independently within the community.’ In June 2007 the minimum fee charged was £800/week, with additional amounts payable for people with particularly high needs. Laural House makes inspection reports and other important information about the home available to residents, their families and professionals. DS0000064230.V336932.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 1 day and lasted 8 hours. Brian Bowie, the allocated inspector for Laural House, carried out the inspection. The manager and assistant manager assisted with the inspection. The inspector spoke to 3 of the 4 residents living in the home at the time of the inspection. The residents are very able to communicate how they feel about living at the home. Throughout the inspection the way in which staff communicated with and supported residents was observed. In addition one member of care staff. the manager and assistant manager were interviewed at length. A variety of records, including care plans, staff files and health & safety documents were looked at. The overall impression is that the skilled and experienced staff team at Laural House is continuing to provide a good and improving standard of care to residents. What the service does well: ‘I’ve had no problems with the staff. The manager and the whole team have been good. So far, so good.’ This was the comment of one resident about his life at Laural House. Feedback from the 2 residents interviewed was very positive about how they found living at Laural House. ‘This is the longest placement this person has had.’ This was the comment of assistant manager in relation to one resident who had a long history of placement breakdowns. The CMHT (Community Mental Health Team) is very pleased.’ The home has a homely and relaxed atmosphere and is kept clean and tidy. Members of staff have got to know the residents very well and understand their individual needs and preferences. As a result residents are able to communicate confidently with staff. There is a committed and experienced team of staff at Laural House who work well together. Staff feel well supported by the management team at the home. The staff team has also had a significant amount of training in working with adults with mental health needs, including those with challenging behaviours. Consequently the residents get the benefit of living in a home where they feel understood and supported. Each resident is seen and treated as an individual in their own right. This approach is giving residents the opportunity to build and develop for themselves a more positive lifestyle than they have had previously. In most cases residents have been through a number of living situations that have not DS0000064230.V336932.R01.S.doc Version 5.2 Page 6 been able to meet their needs. They are now benefiting from being well supported by staff so that in general their mental heath is stabilising and their level of challenging behaviours is reducing. As a result since the house opened in 2006 residents have moved on from Laural House, not as the result of a placement breakdown, but to move to a more independent placement. The management and staff team have worked hard and effectively to achieve this. What has improved since the last inspection? What they could do better: At the inspection of Laural House in June 2006 there had been 6 areas for the home to sort out. This had been done. The high standard of care being achieved means that no requirements are made at this inspection. 3 recommendations to improve practice even further at the home are made: • The manager should ensure that risk assessments indicate the degree of risk so that changes in the assessed level of risk can be more easily identified in order to ensure residents are supported appropriately. The manager should ensure that staff supervision notes always indicate clearly timescales applying to action agreed at these meetings. DS0000064230.V336932.R01.S.doc Version 5.2 Page 7 • • The manager should ensure that staff find further ways to increase the involvement of residents in the running of the home, given difficulties involved in holding residents’ meetings. 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. DS0000064230.V336932.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 DS0000064230.V336932.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): 2 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. • Residents benefit from living in a home that is able to meet their needs since detailed assessments are made before any new person moves into Laural House. EVIDENCE: ‘It’s very relaxed here. It’s cool. I’ve got a clean room and a nice bed. I feel comfortable- people do their own thing- I like my privacy.’ This was the view of one of the residents about living at Laural House. Another resident said: ‘I visited before moving in and was able to choose my bedroom.’ The files for 2 of the residents were looked at and indicated that before they moved in a full mental health assessment had been received by the home. A care plan had then been drawn up by the home showing how the resident’s needs were to be met. Reviews with mental health professionals indicated that residents are appropriately placed and their needs are being met. DS0000064230.V336932.R01.S.doc Version 5.2 Page 10 Observation throughout the inspection, together with the care plans, showed that none of the 3 residents seen is inappropriately placed at Laural House. This indicates that the home is careful to ensure that it is able to meet the needs of new residents and does not admit people whose needs it is unable to meet. The manager meets prospective residents in their current placement so that a detailed assessment can be made of their suitability for Laural House. This is particularly important since the individuals referred to the home have complex mental health needs and may present challenging behaviours. DS0000064230.V336932.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): 6,7,9 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. • • Care plans provided detailed information on how the needs of residents are met. As a result residents feel that they are well supported. Laural House is good at finding ways for residents to make as many decisions for themselves as possible so that residents learn to become more independent. Residents are protected by risk assessments that are comprehensive and indicate clearly how risks to the safety of residents are reduced. • EVIDENCE: DS0000064230.V336932.R01.S.doc Version 5.2 Page 12 ‘I believe Laural House is meeting my client’s needs at present.’ This was the comment of a social worker at one of the resident’s placement reviews. Feedback from the 2 residents interviewed was very positive about how they found living at Laural House. Residents thought their needs were being met and that they were getting on well. The records for 2 residents were looked at and indicated that for each one there was a current plan of care. These set out the needs of the resident and how they are to be met by the home. These plans now make specific reference to the religious and cultural needs of the resident. In one case it had been noted: ‘Staff to continually enquire from the resident about his preferred cultural and religious needs, whilst being mindful of his mixed heritage.’ As a result staff are now taking more account of diversity issues when supporting residents. Throughout the inspection members of staff offered choices to residents. People made choices about when they got up in the morning and when they went out. Residents said they could choose when and what they had to eat and what outings they went on. Where a resident has restrictions on their choices under the Mental Health Act this is stated in their care plan and risk assessments. In one case a resident had had restrictions on their movements gradually reduced, after agreement with relevant agencies, so that the person had more choice on when they went out and for how long. All care plans recognise potential risks to residents and the risks that they may pose to others. The plans outline how these risks can be minimised, for example detailing action to be taken by staff if a resident becomes aggressive or violent within the home. The risk assessments also highlight what things might anger or agitate each resident and how these can be avoided or managed. As a result residents feel more relaxed and settled in the home so that there are fewer incidents of challenging behaviour. Staff interviews indicated that members of staff understand how to support residents. They do this in line with training they have had on how best to manage the challenging behaviours and unpredictable mental health issues presented by the residents. The home is achieving a good standard in this area that is enabling people with complex needs to manage well in a small group living situation. Risk assessments are monitored and reviewed regularly, but do not always clearly indicate the degree of risk. It is recommended that for each area of risk the degree of risk is identified so that changes in the assessed level of risk can be more easily identified. This makes it easier to determine if any changes in the way the resident is supported are needed DS0000064230.V336932.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. • • • • • Residents have a good quality of life because they take part in a range of stimulating activities. Residents are helped to be part of their local community so that they feel less isolated. Staff pay attention to sexuality issues for residents so that they are supported in their relationships with others. The residents benefit by having staff who allow them to make choices for themselves so that have as much control over their life as possible. Residents have a choice about what they eat and enjoy the food provided. DS0000064230.V336932.R01.S.doc Version 5.2 Page 14 EVIDENCE: ‘I go to this mental health project and help out in the office which I’m paid for. I also help with the recruitment of staff.’ This was the comment of one resident who was getting a great deal out of the mental health project he was going to. Residents decide for themselves what they wish to do and when. Each resident is supported by the activities coordinator to extend their range of activities, for example with staff encouragement one resident had been attending an adult education course. A record is kept of activities offered to and taken up by residents. Feedback from residents and staff showed that residents get out and about in their local community, including going shopping, using the library and video shop, going to the cinema and on outings. Residents make use of public transport to get out and about. Where residents have anti-social behaviours staff work hard to reduce some of the difficulties caused, for example by meeting and talking with neighbours. Residents have contact with their families if they wish to. One relative had written: ‘My son is very happy in the home. I have met some of the staff and the residents and everyone seems to be very nice. No problems when I visit the home, and it’s always clean & tidy.’ In some cases residents had girlfriends who they went out with regularly and stayed with some nights. Residents are able to have partners to stay overnight at the house on an agreed basis. In this way staff respect and promote personal and sexual relationships for residents. Laural House has a charter of rights for residents which makes clear what they can expect from the home. The home also has ‘house rules’ which spell out what is expected of residents. As a result everyone living in, or working at, the home knows what is expected of them which is contributing to the generally relaxed atmosphere at Laural House. When a resident does act irresponsibly this is followed up by staff and in conjunction with the CMHT if necessary. ‘The food’s fine- there’s plenty of it. I’ m a vegetarian, like one of the other residents, and I get vegetarian food here.’ This was the comment of one resident who was positive about food in the home. In some cases residents are given money each week so that they can buy and cook their own food so DS0000064230.V336932.R01.S.doc Version 5.2 Page 15 that they are better prepared if they move onto a more independent placement. DS0000064230.V336932.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. • • • Staff are good at meeting the needs residents so that residents feel well supported. Residents like living at Laural House because staff make sure their physical and emotional health needs are met. Residents are protected by the safe and effective arrangements regarding medication in the home. EVIDENCE: • ‘I feel supported now.’ DS0000064230.V336932.R01.S.doc Version 5.2 Page 17 • • ‘Staff don’t ignore you- they’re always ready and available to talk.’ ‘I get help with paperwork, appointments. It’s hunky dory.’ These were comments of residents interviewed and indicate that they are supported well at Laural House. The care plans are detailed and set out clearly how to respond to the needs and wishes of residents, with guidelines about dealing with any challenging behaviours. As a result individuals with challenging behaviours and significant mental health difficulties feel more relaxed which in turn enables them to have improved relationships both with other residents and with staff. Health needs are responded to with evidence seen of referrals made to other relevant professionals. In some cases residents have a fortnightly injection administered by a CPN. Given the complex needs and histories of each resident there is close contact between the home and the relevant psychiatric team. Regular progress reports are sent to other professionals as part of working in partnership with the CMHT. A CPN (Community Psychiatric Nurse) who visits the home regularly was interviewed and commented: ‘Staff are very good. The home will ring me if there’s a serious incident- they don’t panic. They’ll act as appropriate adults in supporting residents if they’re in court. It’s one of the better homes.’ Medication arrangements were gone through with the assistant manager who has responsibility for this area within the home. All staff have undergone training so that they can administer medication appropriately and safely. Medication arrangements in the home are satisfactory, with the temperature in the medication cupboard being recorded as is the date on which residents have had depot injections. DS0000064230.V336932.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. • • The home deals well with complaints so that residents feel confident their complaints and concerns will be listened to and acted on. The residents are protected by adult protection procedures that make sure that they are safe and secure whilst at Laural House. EVIDENCE: ‘Staff listen to complaints.’ This was the comment of one resident. Residents spoken to said they felt able to raise their concerns or complaints with staff and managers. This is particularly important at Laural House since some residents behave anti-socially at times within the home. Residents said they are listened to and staff follow up complaints, for example if one resident is playing their music too loudly. The home has policies and procedures in place in relation to reporting and investigating complaints. The complaints book indicated that complaints are recorded, with appropriate follow up action taken. DS0000064230.V336932.R01.S.doc Version 5.2 Page 19 Staff have attended training courses on how to protect vulnerable adults from abuse and know what to do if they think a resident has been the victim of any form of abuse. In one case action had been taken by staff to minimise financial exploitation of one of the residents by other people. The home has procedures and policies on protecting residents from abuse. There have been no allegations of abuse since the home opened. Records are kept of residents’ monies that are signed by both the resident and a member of staff. DS0000064230.V336932.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. • • Residents at Laural House enjoy an attractive and comfortable living environment that adds to their quality of life. Residents benefit from a home that is kept clean and hygienic. EVIDENCE: ‘When I moved here I chose my own bedroom.’ This was the comment of one resident. Residents were positive about their living environment and throughout the inspection appeared to feel at home at Laural House. DS0000064230.V336932.R01.S.doc Version 5.2 Page 21 Laural House is homely, comfortable and well decorated and furnished. The lounge has a television with a wide variety of channels available. There is a small garden at the back of the property. The home is very close to public transport and shops making it easier for the residents to take advantage of local community facilities. Staff said that repairs are dealt with promptly since one of the support workers has specific responsibilities to deal with maintenance issues. On the day of the inspection the home was clean and tidy. Feedback from a professional who regularly visits the home included the comment: ‘The home is always nice & clean.’ One resident said: ‘One member of staff comes inthey’re brilliant-always cleaning.’ DS0000064230.V336932.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. • • • Residents benefit from a committed and experienced team of staff who have the skills to meet their needs. Residents are protected by the home having thorough recruitment procedures for new staff. Residents benefit from their mental health being stabilised and their independence skills increased because of the skills and competence of staff. EVIDENCE: ‘I’ve had no problems with the staff. The manager and the whole team have been good. So far, so good.’ This was the comment of one resident about his DS0000064230.V336932.R01.S.doc Version 5.2 Page 23 life at Laural House. Feedback from the 2 residents interviewed was very positive about how they found living at Laural House and the support they got from staff. Staff interviews showed that there is a committed team of staff at the home who work hard at meeting the complex needs of the current group of residents. Throughout the inspection staff interacted positively and supportively with residents. Most members of staff have achieved the NVQ Level 2 in care, and have considerable experience in working with people with mental health needs. As a result residents are being skilfully supported which is contributing to their improving mental health. Staff files were looked at and contained the information needed to make sure that all new staff in the home have had the appropriate checks made, including obtaining written references and satisfactory CRB disclosures. As a result residents are protected by the arrangements Laural House has in place when recruiting staff to work at the home. New members of staff have a planned induction into the roles and responsibilities of being a care worker. The staff team has attended a range of relevant courses, including adult protection, administration of medication, challenging behaviours, and mental health awareness. This is in addition to training in essential areas such as first aid, food hygiene, fire safety, and health and safety. As a result staff are more effective in how they manage challenging behaviours so that police are called less than previously and there are fewer psychiatric admissions needed. The home has a comprehensive training plan for 2007 to ensure staff get the training they need and have refresher training when required e.g. for first aid. Staff records showed that members of staff have had a supervision session so that their care practice can be developed and any training needs identified. Staff interviewed said they felt well supported by management at the home. Supervision files seen did not always have timescales for action needed to meet the identified needs of staff e.g. for staff undertaking specific training. It is recommended that staff supervision notes always indicate clearly timescales applying to action agreed at these meetings. DS0000064230.V336932.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. • Residents really benefit from living at Laural House because the home provides a very personalised service to each of the residents in order to meet their needs. The home is run in the best interests of the residents with their views and wishes shaping how the home is run. The home is good at making sure residents are kept safe and secure whilst living at Laural House. • • EVIDENCE: DS0000064230.V336932.R01.S.doc Version 5.2 Page 25 ‘The manager and the whole team have been good. The managers are very available. I’ve enjoyed it here.’ This was the view of one resident who was preparing to leave Laural House to move into a more independent situation. The home is run well with priority given to meeting the needs of residents. The management team and staff have a good understanding of the needs and wishes of each resident. Residents were seen to be relaxed in the presence of staff and confident about interacting with them. The home uses feedback forms and questionnaires to get the comments and views of residents, families and professionals about the service provided by Laural House. The residents interviewed said that they felt listened to by staff and that they were able to make comments about the running of the home. Suggestions for activities are followed up by the activities coordinator. Residents had been provided with double beds where they requested this. One person had wanted access to a particular digital channel so that he could follow his football team and this had been provided. It is recommended that staff find further ways to increase the involvement of residents in the running of the home, given difficulties involved in holding residents’ meetings. At short notice the manager had completed most of the AQAA (Annual Quality Assurance Assessment) that asks for detailed information about the running of the home. Information on the form was checked at the inspection and indicates that Laural House is able to critically assess the quality of the service provided and work towards improving the standard of care further. A range of records was looked at, including health and safety and fire safety. These records were detailed, up-to-date and accurate and confirmed that the home is being run responsibly with essential checks being made and acted on. An independent company had carried out a fire safety risk assessment of the premises. The home had followed this up with a timetabled action plan to implement all the action required. DS0000064230.V336932.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 x DS0000064230.V336932.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA9 Good Practice Recommendations The registered persons should ensure that risk assessments indicate the degree of risk so that changes in the assessed level of risk can be more easily identified in order to ensure residents are supported appropriately. The registered persons should ensure that staff supervision notes always indicate clearly timescales applying to action agreed at these meetings. 2. YA36 DS0000064230.V336932.R01.S.doc Version 5.2 Page 28 3. YA39 The registered persons should ensure that staff find further ways to increase the involvement of residents in the running of the home, given difficulties involved in holding residents’ meetings. DS0000064230.V336932.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 DS0000064230.V336932.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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