Inspection on 18/01/07 for Manor Green Road (62)

This inspection was carried out on 18th January 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Manor Green Road (62) 30/01/06

Manor Green Road (62) 20/09/05

Manor Green Road (62) 05/10/04

Manor Green Road (62) 12/05/04

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Southfields

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33 St John`s Church Road

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

CARE HOME ADULTS 18-65 Manor Green Road (62) 62 Manor Green Road Epsom Surrey KT19 8RN Lead Inspector Lisa Johnson Unannounced Inspection 18th January 2007 08:45 Manor Green Road (62) DS0000013524.V325443.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 Manor Green Road (62) DS0000013524.V325443.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. Manor Green Road (62) DS0000013524.V325443.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Green Road (62) Address 62 Manor Green Road Epsom Surrey KT19 8RN 01372 726131 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) www.caremanagementgroup.com Care Management Group Ltd (trading as CMG Homes Ltd) Mrs Rosaleen Ann Leen Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1) of places Manor Green Road (62) DS0000013524.V325443.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 29 65 YEARS One person may be over the age of 65 years Date of last inspection 30th January 2006 Brief Description of the Service: 62 Manor Green Road is a converted detached property providing accommodation for five service users with a learning disability. The home is located in a quiet residential area of Epsom and has easy access to shops, public transport and other local amenities. The accommodation is provided over two floors. All bedrooms are single rooms with two rooms with en-suite facilities. The communal areas consist of a medium sized lounge, dining room and kitchen/diner area. There are suitable bathroom facilities provided and the home has a large, secure garden to the rear of the property. There is space for one car to park off-street at the front of the property and ample on-street parking. Weekly fees range from £806.23-£1,036.65 Manor Green Road (62) DS0000013524.V325443.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The site visit was unannounced and took place over six hours commencing at eight forty five am until three O’clock. Mrs. L Johnson Regulation Inspector carried out the visit and Mrs.R Leen Registered Manager represented the establishment. The inspector spoke to one service user to gain their views on the care provided. Another service user who was present during this visit declined to speak to the inspector. Two service user comment cards, three relative and three health care professional comment cards have been received. These comments are reflected in this report. During this visit the inspector had the opportunity to speak to the registered manager and one member of staff. A full tour of the premises took place. Pre- inspection information, staff training records, staff files and policies and procedures were sampled. The inspector would like to thank the staff and service for their hospitality and assistance in carrying out this visit. What the service does well: The service provides a warm and homely atmosphere, which is comfortable and well furnished. One service user spoken to stated “This is a nice house and I can choose the colours of paint for my room”. The home promotes independence and decision making which was confirmed by care plans sampled and service user comment cards received. One service user stated, “ I have my own keys and I can come and go when I like”. “ Staff read my care plan to me “. During this visit a number of service users were out attending activities such as college and work”. Service users are supported to undertake domestic skills and cooking and one individual was observed to be using the washing machine. Comments received from service users confirmed that they have to the opportunity to make choices about their meals. Comments received from service users included “ I like living here and the staff are nice”. Manor Green Road (62) DS0000013524.V325443.R01.S.doc Version 5.2 Page 6 Three comment cards were received from relatives, who all stated that they are made to feel welcome when they visit the home and are satisfied with the care provided. One comment received stated, “ They are excellent in everyway”. Positive comments were received from three health care professionals. One comment stated “ “ This is a well run home”. What has improved since the last inspection? What they could do better: The inspector sampled two individual care plans. A recommendation was made that care plans should be signed by the individual to confirm their agreement to their care plan. During this visit individual risk plans were sampled for two service users. It was required that a risk plan for one individual be discussed with and agreed Manor Green Road (62) DS0000013524.V325443.R01.S.doc Version 5.2 Page 7 with the local authority care manager to ensure that this persons health and welfare is protected. At the previous visit it was observed that the service users dining room is used at nighttime for staff sleep- in duties and a requirement was made that this matter must be given attention. Since the previous visit the permanent bed has been changed to a sofa bed and the inspector was informed that staff do not use the dining room during the day. This arrangement still does not provide a suitable and appropriate dining area, separate from the resident’s private accommodation. A written comment was received by the inspector, which states, “The dining room is not freely available to residents as it is used by staff to sleep in”. Therefore a further requirement was made this matter must be attended to ensure that the rights of service users are protected. The home must implement a protocol for the administration of homely remedy medication to ensure service users are protected by the homes medication policies and procedures. During this visit the staff duty rotas were examined and it was noted that a member of staff was working excessive hours during a one-week period. An immediate requirement was made this practice must be reviewed to ensure the health and welfare of service users and staff. Since this visit the registered manager has provided written confirmation to the Commission that this matter has been attended to. During a tour of the home it was noted that radiator covers have not been installed in the home. It was required that a risk assessment is completed to ensure that the health, welfare and safety of service users are protected. 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. Manor Green Road (62) DS0000013524.V325443.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manor Green Road (62) DS0000013524.V325443.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of service users are assessed prior to admission to the home. EVIDENCE: The service users that are currently residing in the home have lived there for a number of years. There is currently one vacancy and the manager said that a new referral has been received. The manager stated that the pre- assessments would be completed. The manager stated that the company has an assessment team who receive initial referrals with the manager having the opportunity to carry out her own assessment. The manager stated that the cultural and diversity needs of service users are considered during this assessment. Manor Green Road (62) DS0000013524.V325443.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 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with an individual care plan, which records their individual needs and goals although improvement is needed to ensure that service users agree to their plans. Service users are supported to make decisions about their lives with assistance. One matter needs attention to ensure that service users are supported to take risks as part of an independent lifestyle. EVIDENCE: Two out of four care plans were sampled. Each service user has a care plan in place and pen portraits were completed. Care plans were based on personal, physical, emotional, and social needs. Plans were observed to be detailed and were reviewed annually, six monthly and monthly and signed by the author. Two comment cards indicate that staff listens to their views. During this visit one individual spoken to stated that he is invited to his care review meetings and stated, “Staff always read my plan to me”. This individual needs support with domestic tasks such cleaning his room and this was confirmed by the Manor Green Road (62) DS0000013524.V325443.R01.S.doc Version 5.2 Page 11 individual. Monthly reviews indicate that progress is recorded which was also confirmed in the daily records. A recommendation was made that this individual signs to agree his care plan. Another individual does not wish to sign their plan and this was clearly documented. During this visit the staff were observed to have a good knowledge of the service users needs. Comments received from health care professionals indicate that, “If specialist advice is given this is incorporated in to the care plan”. Comment cards were received from two service users, which indicate that that they are able to make decisions in their daily lives and staff listen and act upon what they say. One person manages their own finances and another individual requires support, which is recorded in their care plan. The inspector spoke with this individual who confirmed his agreement. One individual spoken to stated that he could choose the colour of the paint in his bedroom. During this visit individual risk plans were sampled for two service users. Plans were in place for one individual who self medicates, personal hygiene, use of the kitchen and emotional related issues. It was required that a risk plan for one individual must be discussed with and agreed with the individual and local authority care manager to ensure that this person’s health and welfare is protected. Manor Green Road (62) DS0000013524.V325443.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. Service users are provided with a range of appropriate activities and engage in a range of leisure activities. Service uses are supported to take part in the local community. One matter needs attention to ensure that the rights of service users is respected. The home is able to demonstrate that service users are provided with a well-balanced and nutritious diet. EVIDENCE: Evidence gathered during this visit indicated that service users have access to a range of appropriate activities. Individuals living in the home are independent and access local community facilities such as shops, banks, pubs and cafés. One individual told the inspector, “ I work in a café and staff help me with my cleaning, vacuuming and ironing”. This individual confirmed that he had been on holiday to the Isle of Wight. During this visit two service users were out attending day activities. The inspector was informed that one individual dislikes attending activities but likes taking herself independently to the bank and shopping. During this visit Manor Green Road (62) DS0000013524.V325443.R01.S.doc Version 5.2 Page 13 this individual was observed to be doing her washing and daily care notes indicated that this individual has made some progress in gaining new experiences. Evidence gathered during this inspection indicated that service users maintain links with their family and friend’s. One individual spoken with said, “ I visit my sister and i have a friend in Epsom with whom I have a coffee with at the café”. Service users are provided with the opportunity to invite their friends for meals at the home. Comments received from relatives indicate that they are made to feel welcome when they visit the home and are able to visit their relative in private. Choices and rights are documented in the care plan and it was evident that service users can make choices in their daily lives. One person told the inspector that he could choose his meals. This individual stated, “ I attend services at the Catholic Church and I go to Lourdes”. When this individual arrived back to the home at lunchtime he was observed to ask staff if any post had arrived for him and confirmed to the inspector that he has access to his post. This individual also said, “ Staff knock on my door and respect my privacy”. Comments received from health care professionals state that they are able to visit service users in private. At the previous visit it was observed that the service users dining room is used at night time by staff for sleep- in duties and a requirement was made that this matter must be given attention. Since the previous visit the permanent bed has been changed to a sofa bed and the inspector was informed that the dining room is not used by staff during the day. However this arrangement still does not provide a suitable and appropriate dining area, separate from the resident’s private accommodation. A written comment was received by the inspector, which states, “The dining room is not freely available to residents as it is used by staff to sleep in”. Therefore a further requirement was made this matter must be attended to ensure that the rights of service users are protected. Menus are planned on a weekly basis with meals being based on individual preferences. One individual spoken to said that he was happy with the meals provided. One individual likes plated chicken meals and cooks this in the microwave. Any changes to the menu were documented. Freezers and fridges were well stocked. Fresh fruit and vegetables are provided. The manager stated that stated that service users have the opportunity to choose and make their breakfast. Manor Green Road (62) DS0000013524.V325443.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. The home is able to demonstrate that service users receive personal support in the way they prefer. Service users physical and health needs are met. One matter needs attention to ensure service users are protected by the homes medication administration procedures. EVIDENCE: Evidence gathered during this visit indicated that the strengths and needs and likes and dislikes of service users were clearly documented and covered areas such as leisure activities and diet. During this site visit one individual doesn’t like people visiting her room and her preference and decision not to do this was observed to be respected by staff. One individual visits his GP independently. Individual health care needs were incorporated in the care plan. There was evidence to suggest that one individual requires support by specialist healthcare specialists. Three comment cards were received from health care indicating that staff demonstrates an understanding of the care needs of service users. Another individual does not like a visting health care professional i.e. for health screen checks this was clearly documented in her Manor Green Road (62) DS0000013524.V325443.R01.S.doc Version 5.2 Page 15 care plan with risk assessments in place. The care plan documents that this individual requires close monitoring of dietary intake and has had a past consultation with a dietician and records were maintained of regular weight monitoring. The manger stated that “My health books” are being introduced. The medication administration policies and procedures were examined. As well as a company policy the Royal Society Pharmaceutical Guidelines identifying good practice were available. All medication administered was signed for. A list was in place for all staff trained and authorized to administer medication. The inspector was informed that staff receive annual assessments. One person self medicates and has a lockable drawer in her room. A risk assessment was in place. Medication is dispensed from Boots in blister packs. Records were maintained of all medication received and disposed of. A requirement was made that the home must implement a homely remedies protocol to ensure that the health, welfare and safety of service users is protected. Manor Green Road (62) DS0000013524.V325443.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 is able to demonstrate that the views of service users are listened to and acted upon. Service users are protected from abuse. EVIDENCE: The home has a complaints procedure in place, which is accessible and meets the needs of service users. The procedure was formulated in pictures and was seen on display in the home. Since the previous visit the Commission for Social Care Inspection had received one complaint, which was appropriately investigated by the registered manager. No other complaints have been received. Two comment cards received from service users indicate that staff listen to them and act on what they say. One individual stated, “that he would talk to the manager and staff if he was unhappy”. During this visit the inspector spoke with one individual who said, “That the staff are nice”. Three comment cards received from relatives indicate that they are happy with the care provided with one relative stating, “ The home is excellent in everyway “. Comment cards received from health care professionals indicate that they have not received any complaints and are satisfied with the care provided. With one health care professional stating, “ This is a well run home”. There have been no referrals made under the safeguarding adults policies and procedures. A Safeguarding adult from abuse procedure in picture format was Manor Green Road (62) DS0000013524.V325443.R01.S.doc Version 5.2 Page 17 seen on display in the home and the local authority safeguarding adult policies and procedures were in available. One member of staff spoken with responded appropriately to a scenario discussed with her as to the actions to be taken if she ever witnessed any abuse taking place. Staff training records sampled indicated that staff have attended safeguarding adults from abuse training and the manager has attended the local authority training. Manor Green Road (62) DS0000013524.V325443.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, 25 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a well-maintained, safe, comfortable, homely and clean environment. The home is able to demonstrate that service users bedrooms promote their independence. EVIDENCE: The home is situated in a residential road near to Epsom Town Centre. A tour of the premises was conducted. A new fitted kitchen has been installed, one bedroom has been redecorated and the carpet replaced. The home was maintained to a good standard and was homely. Two bedrooms with en-suite bathrooms are placed outside to the rear of the house to increase independence. There is a large garden, which was accessible. There is a patio and garden furniture for service users to use during the summer months. There is a separate sitting room and dining room. As stated earlier the dining room is also used as a sleep- in room, which must be reviewed. Manor Green Road (62) DS0000013524.V325443.R01.S.doc Version 5.2 Page 19 Three bedrooms were observed during this visit, which were well furnished, and individually personalised meeting the preferences of service users. The home was cleaned to a good standard and hand washing equipment was supplied through out. Separate washing facilities were available. Manor Green Road (62) DS0000013524.V325443.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, 33, 34 & 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Appropriately trained staff meets the needs of service users and they are aware of their roles and responsibilities. Improvement is needed to ensure that the practice of staff working excessively long hours is reviewed to ensure both the welfare of service users and staff. Service users are protected by the homes recruitment policy. EVIDENCE: The staff rota was examined which indicated that the manager and the deputy manager are the only permanent staff in the home supported by permanent bank staff who are employed by the company. The manager stated that these staff have worked in the home and know the service users well to maintain consistency. The manager stated that two members of staff had left the service. The home employs one member of staff throughout the day. The registered manager also manages another service near by and divides her time. The duty rota reflected the shifts that the manager works in the home. Previous plans have been submitted to the Commission for Social Care Inspection providing information that the present staffing meets the needs of the service users as they are independent and are all out during the day. Comment cards received from relatives indicate that they feel there is Manor Green Road (62) DS0000013524.V325443.R01.S.doc Version 5.2 Page 21 sufficient staff. At nighttime there is one sleep in member of staff. The inspector was informed that there is an on call system for staff to contact if extra support is required. There is a current recruitment plan in process to fill the staff vacancies. The manager said a new permanent member of staff was due to commence shortly and provided evidence of this to the inspector. However it was noted on the duty rota for one week that the deputy was working excessive hours i.e. late shift followed by two long days and another early shift, which also included sleep –in duties. An immediate requirement was made that this matter must be given urgent attention to ensure that the health and welfare of service users and staff is protected. Since this visit the registered manager has provided confirmation that this matter has been attended to. A recommendation was made that the current staffing levels should be reviewed if the service user occupancy increases to ensure that the needs of services users are met. The inspector spoke with the deputy manager who said that she was is waiting to commence the National Vocational Qualification (level 3) and one bank member of staff is completing National Vocational Qualification (level 2). The training records were examined for three members of staff, which included two bank staff. Evidence gathered indicated that staff have received mandatory training including, food hygiene, first aid, medication, fire safety, epilepsy, safeguarding adults, moving and handling. The deputy manager confirmed that she had completed training in culture and diversity. All new staff receives induction and records were maintained on staff files. The recruitment files were also sampled for these three members of staff. Application forms, identification and two written references were in place. The company carries out POVA First and police checks. The company has an equal opportunities policy in place. Documented confirmation was in place indicating that staff have received and have been made aware of the General Social Care Code of Conduct (GSCC). Manor Green Road (62) DS0000013524.V325443.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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is able to demonstrate that service users benefit from a home, which is well run and in the best interests of service users. One matter needs attention to ensure that the health safety and welfare of service uses is protected. EVIDENCE: The registered manager is a qualified nurse and is currently completing the Registered Managers Award. One member of staff spoken with said that she is supported by the manager. The home holds regular staff meetings, which were sampled. The home holds regular service user meetings. Service user quality assurance questionnaires have been updated which were available for viewing. The company has also updated feedback questionnaires to include relatives and other stakeholders. The company holds an annual service users Manor Green Road (62) DS0000013524.V325443.R01.S.doc Version 5.2 Page 23 forum where there is an opportunity for service users to discuss their views and opinions in relation to subjects chosen by service users and issues raised by the feedback questionnaires. Pre-inspection information received indicates that policies and procedures are regularly reviewed and updated. The homes fire records were sampled which indicated that regular cheeks and evacuations are completed. Pre- inspection information provided concluded that regular servicing of equipment is conducted. Water temperature and fridge temperature records were sampled which were regularly monitored. Monthly environmental health and safety audits are conducted. During a tour of the premises all substances hazardous to health (COSHH) were stored and locked away appropriately. Accident records were sampled for two individuals, which indicated that no accident or incidents had occurred since the previous visit. However during a tour of the home it was observed that radiator covers had not been provided. Therefore a requirement was made that a risk assessment be completed to ensure the health, welfare and safety of service users. Manor Green Road (62) DS0000013524.V325443.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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 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 DS0000013524.V325443.R01.S.doc 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Manor Green Road (62) Score 3 X 3 X X 2 X Version 5.2 Page 25 3 3 2 X 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 YA9 Regulation 13(4)(b)(c) Requirement The Registered Person must ensure that a risk assessment in respect of one individuals wishes about their health care is discussed and agreed with the local authority care manager to ensure that unnecessary risks to the health, welfare or safety of service users are identified and so far as possible eliminated. The Registered Person must review the current use of the residents dining room for staff sleep in arrangements and take into account the residents rights to choice, dignity and respect in their home. Timescale for action 18/02/07 2 OP17 23(2) g 3(b) 18/04/07 3 YA20 13 (2) The registered person must 18/02/07 ensure that an agreed protocol is completed for the safe administration of homely remedy medication. The registered person shall DS0000013524.V325443.R01.S.doc 4 YA42 13(4)(a) 30/01/07 Page 26 Manor Green Road (62) Version 5.2 ensure that unnecessary risks to the health and safety of service users are identified and as far as possible eliminated RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. YA6 1 2 Refer to Standard YA6 YA33 Good Practice Recommendations It is recommended that where service users are able to they should sign their care plan to confirm their agreement. It is recommended that the staffing levels are reviewed if the occupancy increases Manor Green Road (62) DS0000013524.V325443.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Manor Green Road (62) DS0000013524.V325443.R01.S.doc Version 5.2 Page 28 - 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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