Inspection on 28/09/07 for Maison Moti

This inspection was carried out on 28th September 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Maison Moti 04/01/07

Maison Moti 09/02/06

Maison Moti 30/08/05

Maison Moti 28/02/05

Maison Moti 31/08/04

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

CARE HOME ADULTS 18-65 Maison Moti 200 Chase Side Southgate London N14 4PH Lead Inspector Caroline Mitchell Key Unannounced Inspection 28th September 2007 10:30 DS0000010639.V336935.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 DS0000010639.V336935.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. DS0000010639.V336935.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maison Moti Address 200 Chase Side Southgate London N14 4PH 020 8440 7535 020 8441 7378 info@maisonmoti.co.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) Maison Moti Limited Ms Judith Mshana Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (15), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) DS0000010639.V336935.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 1 specific service user who is over 65 years of age and has mental health needs may be accommodated in the home. This condition will need to be removed at such times as the service user vacates the home. 4th January 2007 Date of last inspection Brief Description of the Service: Maison Moti is registered to provide accommodation and care for fifteen people under the age of sixty five (65) who have a mental disorder (mental health problems). A condition of registration has been approved for a service user who is over the age of 65 to remain at Maison Moti, as long as the home can meet her needs. The home is situated in Southgate, on a residential street, and blends in well with the other local houses. All the amenities of Southgate are short walk away and the home is well situated for bus and underground transport. Maison Moti Ltd operates this care home and 4 supported living projects for people with mental health problems. The fees are normally £600 to £1,00 for each placement per week, and service users are expected to pay separately for items such as hairdressing and clothes. Following Inspecting for Better Lives the provider must make information available about the service, including inspection reports, to service users and other stakeholders. DS0000010639.V336935.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken on an unannounced basis and took around 5 hours to complete. 1 of the 3 staff members on duty answered the door and told the inspector that the acting manager was ill. The service manager and peripatetic manager arrived soon after the inspector and provided the inspector with help throughout the inspection. The inspector was able to talk in private with 3 residents, 1 of whom showed the inspector around the home. The inspector also spoke with 2 staff in private. The inspector reviewed a number of written records kept in the home including the written records for 2 residents, 3 staff, and the training record kept by the home, along with records regarding health and safety, the business plan and service user guide, complaints, medication, residents’ activities and the food served in the home. During July of this year there was an incident when a leaking toilet flooded the home and caused a lot of damage. The residents were taken away on holiday for a 3 week period to enable refurbishment work to be done in the home. Most of the residents who spoke to the inspector, spoke of this time with good humour and the service manager said that she was pleased with the way that residents rose to the occasion, and looked out for each other while they were away. Only 1 resident told the inspector that they were not keen on being away so long, and this was because they thought of Maison Moti as home, and felt safer and more secure there. What the service does well: What has improved since the last inspection? Although the home was previously well maintained, when there was a flood from an upstairs toilet in the summer, the registered person took the opportunity to redecorate and refurbish a number of areas of the home. New carpets have been provided in a lot of the shared areas and the decorative order is very good throughout. New sofas have also been provided in the lounge and the residents and the staff made appreciative comments about these. The inspector also noted that there has been an improvement in the way that written records are presented and organised generally, making it DS0000010639.V336935.R01.S.doc Version 5.2 Page 6 easier to access and monitor information about the welfare of residents, and the personnel histories of staff. Risk assessments are improved regarding particular restrictions that are placed upon residents and where they selfadminister medication. 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. DS0000010639.V336935.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 DS0000010639.V336935.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): 1, 2, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. Peoples’ needs are assessed and they are not admitted to the home unless there is sufficient information to enable a decision as to whether their needs can be met in the home. Prospective residents have the opportunity to “test drive” the home. EVIDENCE: The inspector reviewed the service user guide and found that it is clear and informative. However, some of the information is out of date due to changes in management, staff and residents. A requirement is made for it to be updated. This requirement has been given a timescale for completion in late December, as the inspector is aware that the registered persons are currently recruiting to the post of manager and other care staff posts. The service user guide states that the home is “committed to providing a service that is unique, needs driven and uncompromising in terms of quality”. It is written in a good size type and includes reference to the gender and cultural mix of the residents. DS0000010639.V336935.R01.S.doc Version 5.2 Page 9 The inspector reviewed the written records of 1 person regarding the process of their admission. It was clear that the home had been provided with very comprehensive information regarding this person’s needs, and a detailed inhouse needs assessment. It was evident from the minutes of the planning meetings that had taken place, that the admission had been very carefully planned in the light of the risks associated with their mental health needs, lifestyle and past behaviour, and that the person had been involved throughout the process. DS0000010639.V336935.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): 6, 7, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service involves individuals in the planning of care that affects their lifestyle and quality of life. Staff understand the importance of people being supported to take control of their own lives. People are encouraged to make their own decisions and choices. The care plans are person centred and are agreed with the individual. The plan is written in plain language, is easy to understand and looks at all areas of the individual’s life. A key worker system allows staff to work on a 11 basis. The care plan is a working document reviewed regularly involving the person. It is kept up to dated and focuses on how individuals will develop their skills and considers their future aspirations. Each care plan includes a comprehensive risk assessment, which is reviewed regularly. Management of risk is positive, addressing safety issues whilst aiming for better quality of life. Where limitations are in place, the decisions have been made with the person and are recorded. EVIDENCE: DS0000010639.V336935.R01.S.doc Version 5.2 Page 11 The inspector reviewed the written records for 2 people living in the home. These were found to be well presented and well organised. Each person’s records included a range of professional assessments, including clear risk assessments, and details of multi-disciplinary reviews. Each person had a personal plan setting out their needs and abilities, and in-house risk assessments that were specific to the risks arising from their mental health needs, history and lifestyle. It was evident that the residents had been involved in the creation and review of these. People had also consented to take part in key worker sessions on a regular basis. 1 of the people whose records the inspector saw had specific restrictions placed upon them based on a risk of fire related to careless smoking. It was evident that this issue had been thought about carefully by all of the professionals involved, and that the person had been consulted and consented to these arrangements. At the last inspection the registered person was required to ensure that, where there are restrictions to service users’ personal freedom, these are clearly documented as part of their risk assessment, and these issues are monitored at each review as part of a multi-disciplinary approach. At this inspection the inspector noted a marked improvement in the documented evidence regarding issues of this nature. There was evidence throughout people’s records that they were properly involved in the care planning process and encouraged to make decisions about their lives on a day-to-day basis, and all of the residents who spoke to the inspector in private confirmed this. In terms of confidentiality the inspector noted that residents files are kept appropriately in a locked cupboard and that there was evidence that they are consulted about the release of information about them to third parties. However, information was available in their written records regarding financial details that, to serve their best interests, might be better kept confidential. A recommendation is made in respect of this. DS0000010639.V336935.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a commitment to enabling people to develop their skills, including social, emotional, communication, and independent living skills. People are supported to identify their goals, and work to achieve them, and have the opportunity to develop and maintain important personal and family relationships. The practice of staff promotes individual rights and choice, but also considers protection of individuals, supporting people to make informed choices. People are involved in meaningful daytime activities of their own choice and according to their individual interests and capability; they have been fully involved in the planning of their lifestyle and quality of life. Where appropriate education and occupation opportunities are encouraged, supported and promoted. They can access and enjoy the opportunities available in their local community, e.g. using public transport, library services, the local pub, and local leisure facilities. People are encouraged to be involved in the domestic routines of the home, they are supported to take responsibility for their own room, menu planning and cooking meals, making sure that they are able to enjoy the food they prefer and like. The meals taken are monitored and people are encouraged to eat a reasonably balanced diet. DS0000010639.V336935.R01.S.doc Version 5.2 Page 13 EVIDENCE: A clear method of monitoring individual 1-1 time is in place. There was plenty of evidence that people get out and about in the local community and are undertaking activities that are designed to enhance their skills, such as going to the gym, cooking, sewing, and various trips out to paces of worship, pubs and restaurants. 1 person who is well over retirement age told the inspector that they are very active and go out with a friend regularly as well as getting out to the hairdresser and to the shops on certain days each week. Another person told the inspector hat they liked going out to the local cafes in the area and that there are nice shops in Southgate. 1 person presents some challenges regarding their motivation to undertake any meaningful activities. The staff and the service manager were able to explain the input and support that is being provided in this area, and this was supported by the written records for this person, who’s wellbeing was being closely monitored in this area. In discussion with the residents it was clear that the home places emphasis on family involvement, and it was evident that people are encouraged to maintain contact with their friends and families. During discussion with the service manager and it emerged that 1 resident was openly gay and, as staff have not received formal training around supporting residents with relationships and sexual health in general, this is recommended. 1 resident told the inspector that respecting residents’ privacy is so ingrained, that the staff have been known to knock on her bedroom door before entering, even when she is standing next to them. The home employs a cook and all of the people who the inspector spoke to said that the food was of a very good standard, and that they were encouraged to make their own choices. The cook told the inspector that there were vegetarians living in the home and 1 person’s records reflected that they are Vegan and are involved in preparing their own meals. The menu showed a good variety of main meals, with lots of fresh fruit and vegetables on offer, and a vegetarian alternative at each meal. DS0000010639.V336935.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each resident’s plan; they give a comprehensive overview of their health needs and act as an indicator of change in health requirements. Staff respect privacy and dignity. People are supported to be independent and can take responsibility for their personal care needs. People have access to healthcare and remedial services, staff make sure that people are encouraged to be independent, have regular appointments and visit local health care services. Staff has access to training in physical and mental health matters and are encouraged and given time to attend other training in specialist areas of work. The home has a medication policy supported by procedures and practice guidance, which staff understand and follow. Medication records are completed, contain required entries, and are signed by appropriate staff. People are given the support they need to manage their medication. If people prefer or where they lack capacity, care staff manage medication. There are safe facilities for keeping medication. Staff administering medication have completed an appropriate medication course. EVIDENCE: DS0000010639.V336935.R01.S.doc Version 5.2 Page 15 The inspector was told by a number of staff about the appointment of a clinical manager, who sees residents on a 1-1 basis. They said that this was a recent development, and had improved the service to residents in terms of their mental health. The service manager explained that a formal referral process is being devised so that this work is more organised and focussed. The inspector spoke to 3 residents who all spoke positively about the support they received from the staff. The inspector also noted that care plans set out the kinds and levels of support people need in the area of their personal care, and emphasised promoting peoples’ independence. The records seen by the inspector gave a good indication of their wellbeing and showed that they receive support to access appropriate health care services. The inspector was shown the arrangements for the storage, administration and recording of medication and found these to be in good order. At the last inspection the registered person was required to ensure that where a resident self medicates that the necessary risk assessments are complete. At this inspection the inspector was able to confirm that this issue had been addressed. DS0000010639.V336935.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an open culture that allows residents to express their views in a safe and understanding environment. Residents say that they are happy with the service, feel safe and well supported. The service has a complaints procedure that is clearly written, easy to understand and is displayed prominently in the home. Residents understand how to make a complaint and are clear about what will happen if a complaint is made. The home understands the procedures for Safeguarding Adults. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding about when incidents should be reported. Training in the area of adult protection, and dealing with challenging behaviour has been provided by the home. EVIDENCE: The complaints procedure is very clear and is readily available for the residents. The inspector noted that it is displayed in the entrance hall along with complaints forms for people to fill in. The residents that spoke to the inspector said that they liked living in the home, that the staff were nice and that they felt safe there. Nobody wanted to make a complaint, although they were clear about whom to talk to if they had any concerns or complaints. People are provided with lots of opportunities to say what they think and it was evident that people felt comfortable about expressing their opinions. No complaints had been made about the home since the last inspection. No adult protection issues have arisen since the previous inspection. Records reflect that staff have recently received an update in their training regarding safe guarding adults, and that most staff have also undertaken additional specialist training regarding dealing with challenging behaviour. DS0000010639.V336935.R01.S.doc Version 5.2 Page 17 . DS0000010639.V336935.R01.S.doc Version 5.2 Page 18 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, 26, 27, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that meets the specific needs of the people who live there. People can personalise their rooms. They also say they the home is clean, warm, well lit and there is sufficient hot water. There has been some consultation with residents about the décor, especially for their own rooms. En-suite facilities are available. The home is comfortable, well equipped and has a programme to improve the decoration, fixtures and fittings. It is very clean and tidy. EVIDENCE: The inspector was shown around the building by 1 resident and also spoke to 2 residents in their bedrooms. During the tour of the building the inspector noted that the home is particularly very well maintained and equipped. Some residents were in the lounge, relaxing or watching the television, whilst others were sitting in the dining area chatting. Some people were relaxing in their rooms and the inspector noted that music from various cultures could be heard coming from their rooms. The inspector noted that in addition to the large DS0000010639.V336935.R01.S.doc Version 5.2 Page 19 screen television, there was a karaoke machine and a computer for residents to use in the lounge. Very good quality, new sofas have also been provided. 6 of the bedrooms have en-suite facilities and in addition there are 3 toilets, 2 bathrooms and a shower room. The communal areas include a large lounge, a smaller sitting room that is the smoking room, a dining area and kitchen. The garden has an attractive patio area. There is a well-equipped utility room and 1 resident told the inspector that there is a rota for when people can do their personal laundry, and that this arrangement works well. The home was noted to be very well maintained and impressively clean throughout. At the last inspection the registered person was required to ensure that the smoking room was redecorated and to ensure that the skirting in the first floor shower/bathroom is re-painted. At this inspection the inspector was able to confirm that these issues had been addressed. DS0000010639.V336935.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have confidence in the staff that care for them. There are consistently enough staff available to meet the needs of the people living in the home, with more staff being available at peak times of activity. The staffing structure is based around delivering outcomes for the people using the service, and is not led by staff requirements. Staff members undertake external qualifications beyond the basic requirements. The registered person encourages and enable this and recognise the benefits of a skilled, trained workforce. The staff receive relevant training that is focussed on delivering improved outcomes for residents. Where training needs are identified, the service is responsive in planning to meet these needs. The service has a good recruitment procedure. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. EVIDENCE: The inspector was provided with a copy of the staffing rota for the period of the inspection. This indicated that there were sufficient care staff to ensure that at least 2 people were on duty during both day and night-time hours to DS0000010639.V336935.R01.S.doc Version 5.2 Page 21 meet the needs of the people living in the home, and that they were supported by suitable numbers of management and ancillary staff. Feedback from staff was that there is a strong core team that people relied on each other for support, while there has been a period of disruption in management and staffing in the home. There have been some vacancies and this has necessitated the use of bank and agency staff, which although the residents have been reasonably well catered for, has not been ideal in terms of consistency. However, the inspector was told that a number of posts have been advertised, and it was evident that the permanent staff were looking forward to the team being back to full complement. Staff were also appreciative of the input that clinical manager provides in terms of training and support. The inspector looked at staff personnel files for 3 people and found that they contained evidence of the necessary recruitment checks, including identification, 2 written references and CRB disclosure information. The staff training showed that they had all completed an induction, there was evidence of a well-planned, ongoing training programme and certificates of the training that staff had completed were included in their records. Several staff are undertaking, or have completed training to NVQ level 2, 3 and 4. In addition other staff are also undertaking other relevant qualifications including occupational therapy training. The registered person must ensure that all staff have an annual appraisal and the inspector was able to confirm that this issue had been addressed. DS0000010639.V336935.R01.S.doc Version 5.2 Page 22 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, 41, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager post is vacant and has been advertised, and in the meantime a senior staff member is acting up and is being supported by the service manager. The staff and management team work to improve services and provide an increased quality of life for residents. There is an ethos of being open and transparent in all areas of running of the home. The team is person centred in their approach. The team promote equal opportunities, and understand the importance of person centred care and effective outcomes for people who use the service. They are positive in their approach to translate policy into practice. The home works to a health and safety policy, all staff are aware of the policy and are trained to put theory into practice. Regular checks of the building and equipment take place to ensure the health and safety of the people living and working in the home. Risk assessments are completed and taken into account in planning the care and routines of the home. EVIDENCE: DS0000010639.V336935.R01.S.doc Version 5.2 Page 23 There has been a period, since the last inspection when the home was without a manager, as the previous manager left. This is being addressed. The inspector was told that an experienced senior staff member is now acting up, and that the manager post has been advertised. The inspector also noted that the service manager was knowledgeable about the needs of the residents and all aspects of the running of the home, and was rota’d to provide management cover in the home, along with a peripatetic manager, as the acting manager was ill during the week of the inspection. The service manager seemed to be quite involved in supporting the management of the home generally. The inspector reviewed the business plan for the home and, although the flood had caused minor disruption in achieving some of the aims, the service manager was able to confirm that progress had been made in most areas, and that work had been undertaken to improve the environment, over and above that which had been planned. Residents have regular meetings and the service manager told the inspector that 1 resident sometimes types the minutes on the computer in the lounge. The inspector reviewed the records of the health and safety arrangements in the home and noted that up to date monitoring records were kept of gas, electrical and fire prevention and safety equipment. A fire risk assessment is in place. Records reflect that staff have been provided with a good range of training regarding health and safety in the home and in house monitoring records are kept up to date for areas such as fridge and freezer temperatures. During the inspection the inspector noted that the written records kept about of residents and staff were better presented and better organised than at the previous inspection. The service manager told the inspector that the provider had been reviewing the corporate policies and procedures, and had progressed to reviewing the local policies and procedures in the home. The provider has introduced a policy of ensuring that all of these are dated. DS0000010639.V336935.R01.S.doc Version 5.2 Page 24 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 2 2 3 3 X 4 3 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 3 27 3 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 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 3 X DS0000010639.V336935.R01.S.doc Version 5.2 Page 25 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. 1. Standard YA1 Regulation 6 Requirement The registered person must ensure that the service user guide is updated to reflect recent changes in managers, staff and residents. Timescale for action 30/12/07 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 YA10 Good Practice Recommendations It is recommended that the registered persons review the way in which financial information that recorded regarding residents in order to protect their best interests. It is recommended that staff be provided with training regarding supporting residents in the area of relationships, sexuality and sexual health. 2. YA15 DS0000010639.V336935.R01.S.doc Version 5.2 Page 26 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 DS0000010639.V336935.R01.S.doc Version 5.2 Page 27 - 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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