Inspection on 07/11/05 for Little Arches

This inspection was carried out on 7th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Little Arches 12/06/07

Little Arches 05/01/05

Little Arches 10/08/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Little Arches 83 Cambridge Street Clifton Rotherham South Yorkshire S65 2ST Lead Inspector Mike Hamstead Unannounced Inspection 7th November 2005 07:25 Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 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 Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 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. Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Little Arches Address 83 Cambridge Street Clifton Rotherham South Yorkshire S65 2ST 01709 517461 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Andrea Briggs Mr. David Lambert Mrs Andrea Briggs Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th April 2005 Brief Description of the Service: Little Arches is a 4-bedded unit for adults with learning disabilities; it is owned by Mrs Andrea Briggs and Mr David Lambert and Mrs Andrea Briggs is both the registered person and manager. A small staff team of four enables Little Arches to provide a homely approach to care enhanced by the small size of the group and the ratio of one member of staff to residents at all times. This ratio increases on occasion such as reviews, trips, appointments etc. The building is a detached property close to Rotherham town centre and residents all have private accommodation for use as bedrooms and share the rest of the house that includes a dining room, large lounge, conservatory, patio and garden. Residents participate in the daily routine of the home including shopping, cooking and cleaning. Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection methodology consisted of interviews with the care manager and all staff on duty, and an examination of the homes records. It also included a tour of the building to observe the accommodation. Additional information of the overall situation had been gained from previous inspection visits. The inspection was conducted by an inspector and commenced at 07:25 and finished at 13:30 and included talking to 3 members of staff, and 3 residents. What the service does well: What has improved since the last inspection? The care manager has introduced a quality assurance resident questionnaire, and included the residents views in the Service User Guide. The homes assessment document has been modified to include all the requirements of the standard. Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 6 The homes agreement/contract has been amended to clarify the residents position whilst accommodated there. The staff supervision document has been improved to incorporate the requirements of the standard. The care manager has recognised the need for a greater quality assurance input to protect the interests of residents. 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. Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 & 5. Potential residents/representatives would have all the information about the home available to them to enable them to understand and decide whether the services the home provides meets their needs. EVIDENCE: A Statement of Purpose gives details of the specific needs met at the home, and the Service User Guide supplements this and now contains copies of the residents views to give potential residents an overview of the care provided. Care records showed that all four residents have had assessments through the Care Management System, and the home has devised its own needs assessment form, to capture those additional assessment elements required by this standard. The care manager has also reviewed the assessment and care planning documentation for the benefit of residents care. The current resident group at Little Arches comprises of four residents all with assessed needs relating to learning disability. Their needs are met in full by a staff group organised and trained to provide care to the individual requirements of each resident. Specialist psychological, psychiatric and counselling services are sought for three residents when required, demonstrating the homes ability to meet residents needs. The care manager also works in liaison with other agencies, e.g. social workers, occupational therapists, physiotherapists, community Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 9 psychiatric nurses, the community adult learning disabilities team and others, dependent upon the specialised needs of residents accommodated. All the current residents were invited to visit Little Arches prior to taking up permanent tenancy, and all admissions were planned and the home is currently full. Emergency admissions do not take place as the care manager feels they could disrupt the compatibility and balance of the resident group. Each resident has a tenancy agreement /contract that now contains a full statement of the terms and conditions required, which enables each resident to have a clear understanding and security of tenure within the terms of this agreement/contract. Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 &10. An accurate and ongoing assessment of all residents enables their individual needs and choices to be met. EVIDENCE: The plans of care were examined and found to be satisfactory, and the care manager has reviewed the whole care planning documentation system to improve it for the benefit of residents. Little Arches is a small group home with a maximum of four residents living there at one time, and this setting provides the opportunity to involve residents in the day-to-day running of the home. This is done by inviting them to participate in the domestic routines of running a home such as bringing their own washing down, cleaning their bedrooms and baking, plus shopping for food and deciding on menus. Residents are consulted regularly with regard to their satisfaction about daily life at the home and more recently via a formal quality assurance questionnaire. All four residents are able to communicate their views via speech on what they would like to see happening in their lives at Little Arches. Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 11 One resident is continuing to be supported to build her confidence following an abusive experience prior to her being admitted to Little Arches in 2004, and staff are adhering with a placing authority directive that the resident has restricted contact with certain family members and friends. Staff have arranged a work placement for this resident at Mencap in Rotherham that she attends on two days a week and staff are hopeful that this may lead to a permanent job for her as the resident would like to work with children. Staff have seen a reduction in another residents obsessive behaviour that involves her hoarding newspapers and magazines, bottles and cartons from the streets, that staff are aware may become a health hazard. This resident is receiving both psychological and psychiatric support, and these behaviours have been dealt with in a non-confrontational manner by the staff at Little Arches. The resident is now voluntarily cleaning her accommodation and disposing of the hoarded items at local recycling centres, and the inspector was able to see her in the adjacent converted garage single bedroom accommodation where she lives. One resident is displaying challenging behaviour, and is receiving specialist support, but will seek out staff if she is agitated and ask for assistance, and another resident was staying with her family in Sheffield. Staff are aware that there are continuing problems with these visits that have been reported by them to the placing authority. The risk assessment file kept at the unit applies the risk assessment policy and records the outcomes in individual case files that are reviewed. The home policy file contains a missing persons procedure to be followed by staff but this has not applied since the last inspection. Residents travel unaccompanied on a regular basis in taxis, community transport or the local handy bus; and attendance at social events are examples of how risk assessments promote independence. Staff are sensitive to the information relating to the personal histories of all of the residents and ensure that this information is kept secure and not discussed in any detail in front of others. Resident’s correspondence, their telephone calls and discussions about individuals at staff handover times are all carried out in private that ensures their confidentiality. Records are stored safely and securely and staff are aware of the need for confidentiality through their induction training and the homes policies and procedures. It is very rare that any resident asks to see their file, but families occasionally ask to look at them. One observation was that the home is not provided with copies of social worker review information for their files and the care manager is taking steps to obtain this information. Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17. Staff enable residents to maintain appropriate and fulfilling lifestyles both in and outside the home subject to any agreed restricted contact. There are plenty of opportunities for personal development, education and occupation, and community links are promoted. The availability of communal and leisure activities provided by staff is outstanding, and contact with family and friends is encouraged and maintained. EVIDENCE: All residents are encouraged to participate in the daily routine of living in a homely environment, and are enabled with staff assistance to clean their rooms and carry out personal laundry tasks including ironing. Other daily living skills are promoted by involvement in sewing and gardening where one resident attends the local St James church for a craft morning every Wednesday and goes to church at the weekend. Residents decide the daily menu where food is generally traditional with pizzas and take aways a frequent alternative. The residents go shopping for the menu items and then prepare them in the kitchen, and some residents like baking. Residents also regularly visit or use Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 13 local amenities such as the hydro- pool at Badsley Moor Lane, the neighbourhood corner shop where they are able to go independently after being seen safely across the road, and the local pub. Both old and new friends are welcome to visit at Little Arches, share a meal and mark special occasions. Residents. There are also many other opportunities for personal development, where residents take part in valued activities, and there was evidence of residents having been leaf picking with staff and then displaying them in a decorative format. One resident attends a day centre three days a week; another also attends Mencap on one day a week Scope where she works in their shop in the town centre one day a week, and also attends a conservation group at Thrybergh Park on another day and Eastwood day centre another day. The most recent arrival attends Mencap on 2 days per week. In addition to the organised structured activities relating to employment and education, residents also go swimming, dancing, and attend the cinema. Day trips provide another form of leisure activity, and the residents visit Thoresby market, go bowling, attend lots of Mencap events, and have been to Cleethorpes and Bridlington twice for day trips. There have been two recent Halloween parties, and a visit to the Civic theatre is booked for the 11th November 2005 to see “Fame”. Holidays are also organised and all the residents went to Blackpool for 5 days in October 2005, and three residents went to Skegness in June for a week, and another resident has been to Brixham with Mencap for a week. Residents contribute towards the cost of the holiday depending on the overall cost, but have a 7 day holiday provided as part of the contracted price. Two residents have contact with their families including visits by family to Little Arches and occasional home visits and overnight stays for the residents. One resident is currently subject to supervised contact with family away from Little Arches, and has a boyfriend who visited on the day of the inspection. Daily routines around the house are subject to the residents living together in harmony. All new referrals are assessed in terms of their compatibility with the existing resident group, before their placement is confirmed. Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21. Personal and healthcare support to residents is promoted by obtaining the necessary advice and assistance when required, but this should be extended to include an annual health check. Medication procedures are satisfactory and audited for resident safety, but attention should be given to issues of ageing illness and death to enable staff to meet resident needs throughout their life. EVIDENCE: Personal support is provided to residents in many aspects of their day to day lives, from assistance with personal hygiene, to suggestions about their appearance and what clothes to wear, and this is carried out in a manner that protects their privacy and dignity. Little Arches operates a key-worker system. Rising and retiring times are flexible subject to the requirements of day care attendance, and residents can generally plan their day to suit themselves. All residents are registered with a General Practitioner and are able to attend the health centre if necessary with staff assistance. In the past different users have required smear tests, scans, a course of diabetic injections, blood monitoring, and dietary and nutrition monitoring, and the care manager is trying to arrange for an annual health check to be undertaken. Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 15 A comprehensive and detailed medical record is available for each resident and staff pride themselves in recognising when residents require medical attention and take appropriate action. The care manager is aware that under guidance from “Valuing People” all residents should have an health action plan, and is taking steps to introduce this document, and this action demonstrates the staff’s commitment to ensuring that the residents healthcare needs are met. Other health services such as dental, ophthalmic are available in the wider community with staff accompanying residents to appointments, and there are currently no residents self-administering their medication. The care manager has looked at the making of Wills by residents and has introduced the subject to them. The care manager should also try to obtain the funeral arrangements of residents from themselves or their representatives. All illnesses are treated at Little Arches whenever possible, and hospital admission would only take place if recommended by a General Practitioner. Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Staff are aware and have knowledge and an understanding of Adult Protection issues that promotes the protection of residents, and staff are now recording residents complaints in the complaints book. EVIDENCE: There is a complaints procedure in operation and one complaint has been recorded since the last inspection and satisfactorily dealt with, following a discussion with the care manager that revealed that it was possible that some resident issues were not being recorded in the complaints book. The care manager has discussed the situation with staff that can only be to the benefit of residents. Each resident is provided with a copy of the home’s complaints procedure, and the care manager has organised that a video recording is given to each resident that asks them to show the video to a friend if they are unhappy about any aspect of their life at Little Arches. Relatives are also provided with a copy of the complaints procedure and are positively encouraged to bring any concerns to the attention of staff. The Rotherham MBC Adult Protection procedure is kept at the home and is included for staff going through induction training. It was established that any placing agency would expect the home to use the Rotherham MBC policy and guidelines in the case of any referral relating to abuse of a vulnerable adult. Staff have received updated training in abuse awareness for the protection of vulnerable residents since the last inspection. Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 30. Little Arches presents as a safe homely and comfortable environment for residents visitors and staff. EVIDENCE: Little Arches is a detached property in its own grounds in a residential area close to Rotherham town centre. The area has plenty of local facilities, such as a park, shops, takeaways and a main bus route and is close to a large senior school. The home is secure and can only be entered after ringing a bell located on the outside wall next to a full-length gate that is kept locked; the wall is full height. When the gate is opened the visitor must go through a lockable conservatory that is pleasantly furnished and into the kitchen that again has a lockable door. Inside there is a dining room that is also used for craft and hobby work, a spacious lounge and three bedrooms on the first floor plus a bathroom and toilet and a stair lift to assist any resident that had an injury or any kind of mobility problem. There is a sleeping- in- room on the second floor of the building. There is a second toilet downstairs for the benefit of residents and staff. Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 18 The adjacent garage has been successfully converted into a self-contained single bed unit with its own lounge, kitchen, bedroom and bathroom that contains a shower and presents as a very desirable and private accommodation for the resident in occupancy. All residents enjoy private accommodation in single bedrooms that are furnished and decorated to their liking. They share a bathroom in the main building and also have access to a second toilet. There is sufficient communal space provided to ensure that all residents are able to enjoy sufficient private space when not in their own rooms. The care manager intends to record in the care plan those items of furniture and fittings not wanted by residents that are a requirement of this standard. Internally the home provides, a swivel bather, handrails, and grab rails in the toilet. External ramps make access to the patio area easier, and grab rails are provided where appropriate in the bathroom, and in the garage annexe, to meet the assessed needs of the resident. A tour of both premises including both private and communal areas found the home to be clean and in a good state of repair and the care manager intends to redecorate the premises in the near future. Bathrooms, toilet and kitchen areas were free of offensive odours and cleaning routines promote the required level of hygiene to protect residents interests. Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, & 36. There is a stable and competent staff team with all staff trained to NVQ Level 2, and staffing levels were satisfactory. Further attention needs to be given to obtaining an umbrella body to process the homes CRB information and to introducing foundation training for staff. EVIDENCE: All staff are provided with a job description, contract of employment including their terms and conditions. The care manager has a deputy acting for her in her absence and between them they undertake the responsibility of organising and managing the other staff members. The staff team are a stable team and have been there for a number of years, and there has been one new member of staff employed since the last inspection who has related experience from another care home in the vicinity. An examination of the new member of staff’s file revealed that all the recruitment and selection procedures were in order with the exception that there was no CRB for her due to the fact that the homes umbrella organisation has gone bankrupt. This member of staff continues to work under supervision until the care manager can organise a new umbrella body for the home. All staff including the care manager frequently work alone with the residents and understand their duties and responsibilities in safeguarding the residents welfare. Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 20 A ‘help’ file is available that contains all the necessary information regarding what agencies/people to contact, with regard to problems with the premises, utilities or any residents. The staff team provide a ratio of 1:4 throughout the day and night but one resident is contracted for 1:1 staff coverage for 6 hours per day that is used flexibly dependant upon the residents needs. There are additional staff on duty as required for trips, reviews, appointments etc. All staff have obtained the NVQ Level 2 qualification, and the care manager continues to try to organise foundation training in addition to induction training for staff. The care manager and the deputy care manager provides support for staff during the working week, and formal supervision is now provided to the principles outlined in the standard that should have a positive effect for the overall welfare of residents. Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Residents continue to benefit from a home run well and in their best interests where their health and safety is generally promoted. The care manager must arrange for the gas boilers to be serviced and for portable appliance testing to be undertaken. EVIDENCE: The care manager holds a Technical Instructor qualification that allowed her to work alongside Occupational Therapy staff at a hospital day centre for patients with learning disabilities for a number of years. She also holds the NAMCW nursery nursing qualification, obtained after 3 years of study. The care manager has also now started the NVQ Level 4 qualification that she is finding both demanding and stimulating. Staff questioned were comfortable with the care managers approach, and there was a good atmosphere in the home and the reaction with residents was both spontaneous and friendly. Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 22 The care manager said that studying for the NVQ Level 4 had made her more aware of the importance of quality assurance generally and she intended to introduce quality monitoring in such areas as an audit of the residents files, and also health and safety audit. A residents questionnaire has been introduced and is available in the Service User Guide. Reviews attended by family and advocates and visits by relatives are also used to establish satisfaction with the care delivered. There are policies and procedures provided for staff and although the residents possess some literacy skills the majority of them have insufficient skills to fully comprehend their case file although assistance by their keyworker is offered with all literacy tasks. Each resident now has a photographic record of their achievements, accomplishments and newly learned skills in addition to the usual photo album of recreational events. The ‘achievements’ record graphically illustrates the progress made by individuals at the home. The health safety and welfare of residents is promoted via induction training at the point of employment and through policy and guidance available to all staff. All residents are assessed regarding their response to the fire safety evacuation procedure, that helps to promote their safety. The care manager has arranged for all statutory training to be undertaken in 2005, and staff are trained in moving and handling, fire safety, food hygiene and further training is planned in first aid including choking risk procedures, and infection control in the interests of all residents. The fire records were up to date, but the servicing of the gas boiler in the main home and the annexe was overdue, and there is a need to undertake portable appliance testing. The stairlift was serviced on the 7th January 2005, and the electrical wiring was checked on the 1st August 2003, and all these checks are required to protect the safety of residents and staff. The care manager intends to forward a copy of her accountants statement to the CSCI to ensure the financial viability of the service provided. Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 23 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 3 3 3 Standard No 22 23 Score 4 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 3 4 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Little Arches Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 2 3 DS0000003135.V260876.R01.S.doc Version 5.0 Page 24 Yes 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 YA34 Regulation 18 Requirement The registered person must ensure that all staff employed receive a satisfactory police check. The registered person must ensure that all staff receive foundation training to Sector skills specification wihin 6 months of appointment. The registered person must ensure that the gas boilers are serviced by a corgi registered person. The registered person must ensure that portable appliance testing is undertaken. Timescale for action 31/12/05 2 YA35 18 31/12/05 3 YA42 23 30/11/05 4 YA42 23 30/11/05 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 YA6 Good Practice Recommendations The registered person should ensure that all relevant review/meeting information relating to residents is maintained on their case files. DS0000003135.V260876.R01.S.doc Version 5.0 Page 25 Little Arches 2 3 YA21 YA37 The registered person should ensure that the funeral arrangements information is obtained for residents. The registered person should ensure that she obtains a qualification at NVQ Level 4 in both management and care by 2005. Little Arches DS0000003135.V260876.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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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