Inspection on 08/02/07 for Longbridge Road (144)

This inspection was carried out on 8th February 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 found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Longbridge Road (144) 16/02/06

Longbridge Road (144) 06/10/05

Longbridge Road (144) 24/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Longbridge Road (144) 144 Longbridge Road Barking Essex IG11 8SP Lead Inspector Ms Gwen Lording Unannounced Inspection 8th February 2007 10:00 DS0000027904.V330049.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 DS0000027904.V330049.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. DS0000027904.V330049.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Longbridge Road (144) Address 144 Longbridge Road Barking Essex IG11 8SP 0208 594 6510 0208 594 6510 johngleaves(johng@outlookcare.org.uk) 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) Outlook Care Ginnette Ann Commons Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000027904.V330049.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2006 Brief Description of the Service: 144 Longbridge Road is a care home providing accommodation and support for six adults with a learning disability. The registered providers are Outlook Care. The home is situated in a busy residential area close to Barking Park and is within easy reach of the local shopping area, Barking Town Centre and there are many easily accessible facilities and amenities within the area. The home is easily accessed by public transport, bus, underground and rail. Parking is restricted as the area is in a residential parking zone. However, visitors may request a parking permit from the home for the duration of their visit. The home is a large semi detached property with five single bedrooms on the first floor and one bedroom with an en-suite and shower on the ground floor. The home aims to integrate the residents into community life and supports them to access and participate in mainstream as well as specialist resources in the community in which they live, within their individual capabilities. On the day of the inspection the fees for the home were £1,149.00 per week. A copy of the Statement of Purpose and service user guide are available in the home, together with a copy of the most recent inspection report. DS0000027904.V330049.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which started at 10.00am and took place over five hours. The registered manager was available during the visit to aid the inspection process. This was a key inspection visit in the inspection programme for 2006/2007. Discussion took place with the manager, acting deputy manager and a member of care staff, who were asked about the care that residents receive, and were also observed carrying out their duties. The inspector was able to talk to five of the six residents living in the home and asked their views on the service and their experience of living in the home. The inspector also had the opportunity to speak to an independent advocate who was visiting the home on the day of the inspection. A tour of the home was made and all areas were clean and tidy with no offensive odours. Residents files were viewed, together with examination of staff and other home records, including medication administration, accident/ incident records, staff rotas and staff recruitment files. Information was also taken from a pre-inspection questionnaire completed by the manager. The inspector would like to thank the residents and staff members for their input during the inspection. What the service does well: All the residents have an independent advocate. The advocate has monthly meetings with all the residents, attends their reviews and assists and supports individuals to make decisions about their lives that they are able to understand. Opportunities for social and leisure pursuits and personal development are actively promoted and supported by staff, to enable residents to participate in the wider community in which they live. The registered providers Outlook Care, actively consult residents on how the service is run and can be further developed. There are a number of user groups and forums, and staff encourage and support residents to be involved. During the inspection staff were observed providing residents with assistance and support and were respectful of their right to make decisions. Staff support residents to maintain and establish links with family and friends, inside and outside the home, and their involvement is encouraged, with individual residents agreement. DS0000027904.V330049.R01.S.doc Version 5.2 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. 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. DS0000027904.V330049.R01.S.doc Version 5.2 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 DS0000027904.V330049.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3, 4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide provides prospective residents and their relatives/ representatives with all the information they need, and in an appropriate format, to enable them to make an informed choice about whether they wish to live in the home. Assessments undertaken by the home and the information and reports received from health and social care professionals means that staff have detailed information to enable them to determine whether or not the home can meet a prospective residents needs. EVIDENCE: The home has a Statement of Purpose and Service User Guide. These are in a part pictorial format and are informative, well presented and provide residents with a good understanding of the service and facilities. There are currently no vacancies at the home. Four of the residents have lived in the home since 1995. The two other residents have lived in the home for two and a half years and eighteen months respectively. From viewing preadmission assessments/ documentation it was evident that a full assessment is undertaken, prior to the admission of any resident to the home. There is DS0000027904.V330049.R01.S.doc Version 5.2 Page 9 always a planned phased in introduction to the home and the other residents. The length of this process would be dependant on individuals needs. Each resident has a Licence Agreement/ Contract, which is in a part pictorial format. There was evidence to show that where capable residents and/ or their representatives had signed the contract. The Care Homes Regulations 2001 have been amended with effect from the 1st September 2006 for new residents, and for existing residents with effect from the 1st October 2006, so that more comprehensive information is to be included in the service user guide. Details of information to be included are contained within the amended regulations. Therefore, the service users guide must be reviewed and amended by the stated timescales. The manager was also provided with a copy of the Commission’s ‘Policy and Guidance on Provision of Fees Information by Care Homes’. DS0000027904.V330049.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are detailed and provide staff with the information they need to satisfactorily identify and meet residents personal, social support and health care needs. The home maximises independence wherever possible and staff provide residents with information, assistance and support to make decisions about their own lives. Residents know that the staff handle information about them appropriately, and their confidences are kept. EVIDENCE: Individual files were available for each resident and the records of four residents were case tracked. Care plans are developed for each resident following the principles of person centred planning and each resident has such DS0000027904.V330049.R01.S.doc Version 5.2 Page 11 a plan that has been agreed with them. The ‘Person Centred Plan’ (PCP) is presented in a part pictorial format, which residents can easily access and understand. It identifies needs, likes, dislikes and considers all areas of the residents life including health; personal and social care needs. Staff support and encourage residents to be involved in the ongoing development of their plan and have used a variety of ways to enable residents to contribute and make the process interesting and worthwhile. Each resident has a separate health plan and a daily communication diary. The PCP is reviewed regularly involving the resident, key worker, advocate and, where agreed, their families. The inspector spoke to two residents about their PCP’s. It was clear that these had been drawn up with the individuals’ involvement and that they had contributed to the information contained in it. One resident commented: “Those are my pictures to show what I do”. Another said: “It’s my book, it’s about me”. All of the residents have an independent advocate from Mencap who has a contract with the registered providers, Outlook Care. He has monthly meetings with the residents, attends their reviews and assists individuals to make decisions about their lives that they are enabled to understand. The advocate was attending the monthly meeting with the residents and the later the inspector took the opportunity to speak to him. He was very positive about the care residents were receiving in the home. He had some concerns about the age range and needs of residents currently living in the home as the eldest resident is 67 years and the youngest is 29 years of age. However, he considered that staff in the home make every effort to meet the individual needs of residents in relation to their age, interests and capabilities. The inspector viewed the risk assessments for all the service users. Risk assessments are in place, but can be improved. These are reviewed every three months or sooner where appropriate. However, risk assessments must be re-stated to reflect changing needs and record how decisions have been made and who was involved. There is a focus on maintaining and promoting independence whenever possible, and individual staff were observed providing residents with information, assistance and support and were respectful of their right to make decisions. The registered organisation Outlook Care actively consults residents, across the organisation, on how services are run and can be further developed. There are a number of user groups and forums and staff in the home encourage and support residents to be involved. Information for residents and policies and procedures are presented in formats that residents in the home are able to understand. A recent initiative by Outlook Care is a pilot project in the development of multi media Person Centred Planning. It involves using different forms of media; including photography, video, digital cameras, and music to build and develop PCP’s into more than a written/ pictorial record. DS0000027904.V330049.R01.S.doc Version 5.2 Page 12 This will be used as a working document that is more meaningful with a high level of participation by the individual. DS0000027904.V330049.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities for social and leisure pursuits and personal development are actively promoted and supported by staff, for all residents to enable them to participate in the wider community in which they live. Residents have appropriate relationships and their rights are recognised in their daily lives. Residents are offered a varied and balanced diet and are consulted about their choices of food and participate in shopping. EVIDENCE: Each resident has a planned activity programme, which takes account of the resident’s preferences, interests, experiences, age and capabilities related to their disability. There had been a heavy snowfall overnight and most of the planned activities for the day had been postponed due to the inclement weather and the problems with transport e.g. dial a ride. One resident was asked about the opportunities that he has to attend college, employment and DS0000027904.V330049.R01.S.doc Version 5.2 Page 14 other social activities. He told the inspector that he was appointed last year as one of the Commission’s ‘Experts by Experience’. This involves accompanying regulation inspectors once a month whilst they are undertaking inspections of care homes for adults with a learning disability. He has been supported through the process of application, appointment, training and whilst undertaking inspections, by the independent advocate. The resident is clearly finding his involvement in this role very enjoyable and fulfilling. Through discussion with staff and viewing activity programmes the inspector was able to evidence what social and other activities residents are involved in. This included attendance at college for literacy skills, arts/ crafts and horticultural training; placement at a local farm; membership of a gym and attending social clubs with friends. One resident is a keen supporter of a local football club and goes to games with a member of staff. Some residents attend specialist day centres and others have programmes of activities in the home being managed/ supervised by staff. All residents are supported to participate in leisure activities in the community, both specialist and mainstream. Residents have an annual holiday or short breaks/ days out together or in small groups. One resident was supported by staff to go on holiday with her long term boyfriend, which they both very much enjoyed, and hope to repeat this year. On the day of the visit staff were observed to be supporting individuals to pursue their individual interests and hobbies. Where appropriate residents are involved in taking some responsibility for their own room. One resident said: “ I look after my own room, but staff need to help me sometimes”. All five residents spoken to said that they were “happy” living in the home and they felt staff looked after them well. During the inspection, the residents were observed accessing all areas of the home independently. One resident confirmed that he liked to spend time in his bedroom and was able to do this. The home has limited facilities for private meetings but service users are able to use their bedrooms. Those residents spoken to indicated that they liked the food and there is sufficient choice. The staff prepare and cook meals with some involvement from the residents and staff know what each person likes to eat. The lunchtime meal was observed to be very relaxed, staff were patient and helpful, and several residents prepared their own lunch. During the visit, the inspector checked the food stores and menus. There was a variety of food available at the time of the inspection, which included meat fish, dairy produce; and fresh fruit and vegetables. The menu that was viewed constitutes a varied and nutritious diet taking into account personal preferences. Staff support residents to maintain links with family and friends, and their involvement is encouraged, with individual residents agreement. One resident regularly goes out with her mother. DS0000027904.V330049.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer and their physical and emotional needs are closely monitored to ensure that their needs are recognised and met. There are clear medication policies and procedures for staff to follow. However, there are some inconsistencies in the recording of medication, which may result in unsafe practices. EVIDENCE: All of the care and health plans examined, clearly recorded referrals to specialist health care professionals and that appointments were being kept. Records indicated that residents have attended routine health appointments including GP, dentist and chiropodist. Residents have regular reviews of their medication undertaken by their GP. There was evidence that support is in place to help residents with their personal care. Staff were observed to be providing residents with sensitive and DS0000027904.V330049.R01.S.doc Version 5.2 Page 16 flexible personal support and all such support is provided in private. One of the residents spoken to confirmed that she is happy with the support she receives around her personal care needs. There are policies and procedures in place for the handling and recording of medication. Medication is stored in a locked medicine cupboard in the staff office and is appropriate to ensure the safekeeping of medicines in the home. An audit was undertaken of the management of medicines in the home, and Medication Administration Record (MAR) charts were examined. None of the residents are currently able to self medicate. The registered manager must ensure that all hand written entries on MAR charts are signed and dated by the person making the entry and include the source of the information e.g. GP. Information provided in the pre inspection questionnaire that was sent to the Commission states that six members of staff are responsible for the administration of medication and five members of staff hold a current first aid certificate. This was evidenced on staff training records examined during the visit. DS0000027904.V330049.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and staff make every effort to sort out problems and concerns. However, all complaints or concerns must be routinely recorded so it is clear that any concerns or complaints have been acted upon and resolved. All staff working in the home have received training in adult protection/ abuse awareness to ensure that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: There are policies and procedures for dealing with complaints, which is also produced in a part pictorial format that is well presented and more easily accessible by the resident group. The inspector spoke to three residents about what they would do if they were unhappy with anything. All three residents said:”I would speak to the manager (Ginnette) or one of the staff”. One resident also said: “I could speak to James (the advocate)”. Each resident has a named advocate, who visits him or her once a month. The complaint log was examined and this recorded the number of complaints/ concerns, action taken and the outcome for the complainant. However, the last recorded complaint was dated July 2005. The manager must ensure that staff routinely record all verbal issues of concern or dissatisfaction expressed, so it is clear that such concerns have been acted upon and resolved. DS0000027904.V330049.R01.S.doc Version 5.2 Page 18 There is a written policy and procedure for dealing with allegations of abuse and whistle blowing. All staff have received training in adult protection/ abuse awareness, and this is included in the induction training for all new staff. Those staff spoken to during the inspection, including an agency member of staff, were aware of the action to be taken if there were concerns about the welfare and safety of residents. DS0000027904.V330049.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 26 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises are homely and the atmosphere in the home is very welcoming. The living environment is appropriate for the particular lifestyle and needs of the residents and is clean, safe and comfortable. EVIDENCE: The home was toured at the start of the inspection, and all areas were visited later accompanied by one of the residents. All the bedrooms are single and the one bedroom on the ground floor has an ensuite facility with a shower. Three bedrooms were visited by the inspector, accompanied by the respective resident, and at their invitation. These rooms were furnished and decorated to suit individuals’ preferences and particular needs; and are reflective of their interests and lifestyles. It was noted that one resident was able to lock his door whilst in the room, but the lock was damaged and he was not able to lock the door when his room was unoccupied. This was brought to the attention of the manager who said she was not aware that the lock was broken and would report the lock for repair as a matter of priority. The shower chair in the en DS0000027904.V330049.R01.S.doc Version 5.2 Page 20 suite shower room requires replacing as the plastic coating has peeled off in some areas, exposing the metal frame. The manager stated that a new shower chair has been ordered. All areas of the home were clean, tidy and free from odour throughout. There is a small utility room, which residents are able to use with the support of staff. There is a small secluded rear garden with ramped access. The home is close to community facilities and local services with good transport links. Since the last inspection the upstairs shower room, which was very small, and the adjoining bathroom have been converted into one larger bathroom with separate shower. New units have been fitted in the kitchen; all bedrooms have been re-decorated, bedroom furniture replaced and are scheduled to be fitted with new carpets. The lounge has also been re-decorated and the carpets will be replaced along with the other communal areas of the home. The residents are fully involved in decisions about the décor and any changes to the accommodation. DS0000027904.V330049.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are satisfactory and there are sufficient staff on duty to meet the individual assessed needs of the residents. The procedures for the recruitment of staff are robust and provide safeguards for people living in the home. EVIDENCE: The duty rota was inspected and reflected the staff on duty in the home at the time of the visit. The deputy manager was in charge with one member of bank staff. The manager was the ‘on call’ duty person and arrived shortly after the start of the inspection. The home uses agency/ bank staff to make up any shortfalls for annual leave, training or sickness. The manager tries hard to restrict the number of agency/ bank staff used to a minimum to ensure there is a continuity of care for residents by staff they are familiar with and who understand their needs. There has been a higher use of agency/ bank staff recently as the home currently has vacancies for two support workers. However, there was evidence to show that the home is actively recruiting to these posts. DS0000027904.V330049.R01.S.doc Version 5.2 Page 22 In discussion with staff on duty it was evident that that they understand and fully support the main aims and values of the home. The section at the bottom of the duty rota for agency/ bank staff, does not always clearly record the names or hours of duty for these staff. Through discussion with residents and observation of staff interaction with individuals, it is evident that they have confidence in the staff that care for them, and that staff have a good understanding and knowledge of the particular needs of the residents. Staff were seen to have the skills to communicate effectively with all residents. Only one member of care staff has been appointed since the last inspection and their personnel file was examined. This was found to be in good order with necessary references; Criminal Records Bureau (CRB) disclosures and application forms duly completed. Staff files showed that staff had undertaken essential training in first aid; fire safety; food hygiene; health and safety; manual handling and adult protection. Other training undertaken by staff includes mental health awareness; autism awareness, dementia awareness and aspects of ageing. The pre-inspection questionnaire completed by the manager states that 85 of care staff are qualified to National Vocational Qualification (NVQ) level 2 or above. Staff records show that all staff have regular supervision and appraisal, and staff meetings are held monthly with written minutes being kept. DS0000027904.V330049.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, 41, 42 & 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is efficiently managed, residents interests are safeguarded and they benefit as the home is run in their best interests. EVIDENCE: The current manager is registered to manage this home and a similar home two doors away (148 Longbridge Road). She is well experienced to manage the home and demonstrates a clear understanding of the needs of the residents. It was very evident that the home is operated for the benefit of residents, and every effort is made to retain the independence of those people living in the home and for them to exercise choice and control over their lives. The dependency levels of the current resident group are very variable, and are well considered by staff when providing the level of assistance and support needed by the individual resident. The routines of daily living and activities are flexible DS0000027904.V330049.R01.S.doc Version 5.2 Page 24 and varied to suit the differing needs of the residents together, with their religious and social preferences. Currently the manager does not act as an appointed agent for any resident. Residents financial affairs are managed by their relatives/ representatives. The home has responsibility for the personal allowances of residents and secure facilities are provided for their safekeeping, with records being maintained. A representative of the registered organisation undertakes monthly Regulation 26 monitoring visits to monitor and report on the quality of the service being provided in the home. A copy of the report is sent to the Commission. A wide range of records were looked at including, fire safety; emergency lighting; recording of water temperatures; accidents/ incidents and portable appliance testing (PAT), which is scheduled to be undertaken in one weeks time. These records were found to be in good order, up to date and accurate. DS0000027904.V330049.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X 3 3 3 DS0000027904.V330049.R01.S.doc Version 5.2 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 YA9 Regulation 13 Requirement The registered manager must ensure that risk assessments are re-stated to reflect changing needs and record how decisions have been made and who was involved. The registered manager must ensure that all hand written entries on Medication Administration Record (MAR) charts are signed and dated by the person making the entry, and include the source of the information. The registered manager must ensure that staff routinely record all complaints or concerns, so it is clear that such concerns or complaints have been acted upon and resolved. The registered manager must ensure that the broken lock to the residents bedroom is repaired as a matter of priority, to ensure that the residents dignity and privacy is respected. The registered manager must ensure that the duty rota clearly records the names and hours DS0000027904.V330049.R01.S.doc Timescale for action 01/04/07 2. YA20 13 08/02/07 3. YA22 22 08/02/07 4. YA26 12 & 23 28/02/07 5. YA33 17 Schedule 4 08/02/07 Version 5.2 Page 27 worked by agency and bank staff. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000027904.V330049.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 DS0000027904.V330049.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!